Poor weight gain in late third trimester: a predictor of poor perinatal outcome for term deliveries?

In many parts of the world weighing women in antenatal clinics is no longer thought to be important. At Port Moresby General Hospital we noticed that failure to gain weight in the third trimester (or weight loss) was associated with poor perinatal outcomes. To investigate this issue we designed a prospective case-control study to determine whether poor weight gain in the third trimester is a useful clinical indicator of poor placental function by being associated with intrauterine growth restriction (IUGR) or inadequate placental function in labour by being significantly associated with suspected intrapartum fetal compromise, birth asphyxia, meconium aspiration syndrome and neonatal intensive care unit admission. We found that a failure to gain weight for more than three weeks preceding the onset of labour was significantly associated with intrapartum fetal compromise (OR 2.24), IUGR (OR 2.88), meconium aspiration syndrome (OR 4.19), the presence of thick meconium or the passage of meconium during labour (OR 2.26) and the need for admission to the neonatal intensive care unit for more than 24 hours (OR 2.22). Weighing women in the antenatal clinic setting is a useful way of screening for deteriorating or inadequate placental function, and is particularly relevant in settings where more sophisticated modalities of screening and diagnosis of placental function are not available.

A case-control study of VDRL-positive antenatal clinic attenders at the Port Moresby General Hospital Antenatal Clinic and Labour Ward to determine outcomes, sociodemographic features and associated risk factors.

Between June 2001 and December 2002, 152 antenatal patients at Port Moresby General Hospital who were Venereal Disease Research Laboratory (VDRL) serology positive and 150 unselected antenatal patients who tested negative were studied to determine the gestational age at which the tests were performed, the time it took for results to become available, the proportion of patients who received treatment, the sociodemographic characteristics associated with VDRL positivity and the effect of VDRL positivity on maternal and perinatal outcomes. The prevalence rate of VDRL positive among antenatal clinic attenders in Port Moresby at that time was 4.4%. Of the 152 VDRL-positive patients in this study 97% were also Treponema pallidum haemagglutination (TPHA) positive. Significantly more of the positive patients were of highlands origin, lived in settlements, had previous marriages, had lower parities, delivered preterm babies, had stillbirths, had growth-restricted babies and had babies with lower Apgar scores at both 1 and 5 minutes. The mean birthweight was significantly lower among the positive patients. Significantly more of the positive patients were married to spouses with occupations which were regarded as 'risky' for sexually transmitted infections. There was no difference between the two groups with respect to patient's education, marital status, husband's education, gestational age at delivery and the number of days the baby spent in the Special Care Unit. The study concluded that the current antenatal screening does not provide adequate coverage for our patients. If the current availability of clinic-based strip tests provided by a non-government organization can be continued by the Ministry of Health we should be able to overcome this problem.

Syphilis serology testing: a comparative study of Abbot Determine, Rapid Plasma Reagin (RPR) card test and Venereal Disease Research Laboratory (VDRL) methods.

Blood from 2100 women attending the antenatal clinic of the Port Moresby General Hospital (PMGH) and the 9 Mile urban clinic of Port Moresby was tested for syphili using the laboratory-based Venereal Disease Research Laboratory (VDRL) syphilis serology test and two clinic-based syphilis tests, Abbot Determine and Abbot Syfacard-RR (Rapid Plasma Reagin (RPR) card test). The Abbot Determine and the Syfacard-R tests were compared with the VDRL test, the gold standard in this study. The validation test results of Determine versus VDRL were as follows: sensitivity 92.0%; specificity 94.6%; the predictive value of a positive test 42.6%; and the predictive value of a negative test 99.6%. The validation tests for RPR versus VDRL were as follows: sensitivity 56.3% specificity 96.5%; predictive value of a positive test 41.2%; and the predictive value of a negative test 98.1%. The RPR test costs 3.5 kina (about one US dollar) a test, the VDRL less than 1 kina a test whilst the Determine test kit costs about 5 kina a test. When laboratory time, salaries and other supplies are costed the Determine test is expected to cost relatively much less. Our recommendation is that the Determine test be made available in areas of the country where VDRL is unavailable or where logistics do not allow for test results to be available early enough to make a difference to the care of th pregnant woman and her fetus.

The aetiology of severe anaemia among antenatal patients of the Port Moresby General Hospital.

Between October 1998 and September 2000, 111 consecutive pregnant patients admitted to the Port Moresby General Hospital antenatal ward with a haemoglobin level of 6 g/dl or less were studied. The main causes of the severe anaemia were as follows: iron deficiency on its own or in combination with another factor 66%--iron deficiency on its own 43% and combined folate and iron deficiency 23%--and folate deficiency 18%. Malaria was a contributory factor in 13 patients (12%). A combination of blood film, bone marrow study, serum assays of ferritin, folate and vitamin B12, and mean corpuscular volume (MCV) was used to determine the cause of the anaemia. Ferritin levels on their own poorly correlated with the presence of iron in the bone marrow. A low MCV correlated well with iron deficiency anaemia while a high MCV was associated with folic acid deficiency. It would seem therefore that while a bone marrow study is mandatory to reach a definitive diagnosis of severe anaemia, MCV, in conjunction with the red cell morphology on blood film, would be a good marker for iron and folic acid deficiency anaemia, especially as we do not have serum assays readily available for folate, ferritin and vitamin B12 in Papua New Guinea.

Awareness of and attitudes towards HIV among pregnant women at the Antenatal Clinic, Port Moresby General Hospital.

BACKGROUND: The prevalence of HIV (human immunodeficiency virus) among pregnant women in Port Moresby has increased tenfold, from 0.08% in 1994 to 0.8% in 2002. To stop a further epidemic spread as seen in sub-Saharan Africa it is urgent to identify and intervene to reduce risk behaviours. In order to do so it is important to evaluate current awareness of and attitude towards HIV. METHODS: Interviews with 122 pregnant women were conducted at the Antenatal Clinic, Port Moresby General Hospital, Papua New Guinea. We assessed the women's HIV awareness and relate the results to education and socioeconomic factors. RESULTS: 4 out of 122 women did not know about HIV. 97% knew that HIV is spread by sexual contacts, 96% knew about mother-to-child transmission and 69% knew about infection through breastfeeding. However, there were many misconceptions; 36% believed that HIV can be spread by mosquitoes and 17% believed that caring for an AIDS (acquired immune deficiency syndrome) patient is a risk. Among the women with no education or primary school education only, 51% knew for sure that HIV is not spread by caring for an AIDS patient, compared to 86% for the women with higher education. 47% of the women received their first information about HIV through the media. CONCLUSIONS: The AIDS campaigns have been successful in making almost all the women aware of HIV as a sexually transmitted disease. However, the high frequency of misconceptions makes it probable that patients are stigmatized. This is particularly true for the lower educated women. To more effectively fight the HIV epidemic it is important to improve the general level of education of both men and women, to encourage women to be more in charge of their own sexuality and to increase their status in society. It is also important to make men aware of their responsibility to practise safe sex.

Factors associated with success or failure in trials of vacuum extraction.

Failure rates for vacuum extraction of between one in 16 and one in 600 have been reported. Most studies report that unexpected failure carries a greater risk to both mother and fetus. The aim of this study was to determine factors that were likely to predict success or failure in trials of vacuum extraction. At the Port Moresby General Hospital, 59 trials of vacuum extraction were performed between 1 December 1997 and 30 November 1999. These cases were analysed according to whether vacuum extraction was achieved with more than or less than three pulls, or an alternative method of delivery was required to effect delivery Factors that were predictive of failure were: (i) Highlands origin of the mother; (ii) longer duration of the second stage of labour; (iii) severe moulding of the fetal head; (iv) cup detachments and deflexing cup applications; and (v) operator persisting with the procedure after three pulls. The cervix being less than fully dilated when the trial was commenced was not associated with a higher risk of failure, nor was it associated with a significantly higher risk of cervical trauma. Perinatal death and serious fetal scalp trauma were associated with deflexing cup applications, making more than three pulls and failed vacuum extractions.

Perinatal outcome and associated factors of persistent breech presentation at the Port Moresby General Hospital, Papua New Guinea.

A study of 502 singleton persistent breech presentations and 502 controls of cephalic presentations during labour, at the Port Moresby General Hospital, was carried out from January 1988 to July 1993. In 76 (15%) of the cases, at least one attempt was made at external cephalic version. Backward logistic regression analysis showed that Momase or Islands region ethnicity, previous breech delivery, lack of antenatal care, preterm delivery, low birthweight and congenital anomalies were significantly associated with persistent breech delivery. The perinatal outcome of babies with breech presentation was worse than among babies with cephalic presentation.

Anaemia and perinatal outcome in Port Moresby.

In 1987, a computerized obstetric database was set up at the Port Moresby General Hospital. Between 1987 and 1992, 27,117 births took place. The mean haemoglobin value amongst the 83% of women in whom a haemoglobin value was tested was 10.0 +/- 1.7 g/dL. High stillbirth rates (94 per 1,000) were associated with a haemoglobin value < 6 g/dL. The stillbirth rate was slightly lower (14 per 1,000) in woman whose lowest haemoglobin value was in the range 10.0-10.9 g/dL than in those with a haemoglobin value > or = 11 g/dL (18 per 1,000). The stillbirth rate was increased in women with haemoglobin values > or = 14.0 g/dL. With respect to low birth-weight (< 2,500 g), the rates were also higher when the haemoglobin value was above 14.0 g/dL. The reason for these findings is not apparent and may be due to the impact of an uncharacterized confounding variable rather than the haemoglobin value.

A survey of pregnant women with tuberculosis at the Port Moresby General Hospital.

From March 1995 to February 1998, 110 patients diagnosed with tuberculosis (TB) in pregnancy or the puerperium at the Port Moresby General Hospital (PMGH) were surveyed. 96% were diagnosed as a result of the symptoms of tuberculosis, 4% through contact tracing. 11 of 40 patients who first attended antenatal clinic in the second trimester were not diagnosed until after delivery. The mean birthweight of term infants of TB patients was significantly less than term infants in a previous survey at PMGH. 45% of babies were growth restricted. With increasing duration of treatment, both increasing maternal weight gain in pregnancy and higher mean birthweight were found. Maternal and perinatal mortality were high in the study patients. There were 6 maternal deaths and a perinatal mortality rate of 137/1000. The majority of maternal and fetal losses occurred in patients who had pulmonary, miliary and meningeal TB. Improvement in the detection of tuberculosis in antenatal patients and the introduction of adequate treatment before delivery should prevent maternal deaths and perinatal morbidity and mortality.

Reporting of lactation and normal menstrual information by Papua New Guinean women.

As part of a survey of 600 women enrolled in a study of postpartum progesterone-only contraception (400 women who opted to use progesterone-only contraception and 200 controls) participants were asked about menstrual history and lactation experience. The mean longest menstrual cycle duration was found to be 29.5+/-SD3.5 days and the mean shortest cycle duration was 26.6+/-SD2.8 days. The mean duration of menstrual bleeding was 3.75+/-SD1.16 days. Few women reported menstrual period problems such as dysmenorrhoea (6.5%) and menorrhagia with clots (0.7%). However, 3% of the women reported irregular cycles with intervals of longer than 1 month. Overall the women reported breastfeeding their previous baby for a mean duration of 14 months. The group of women electing to use hormonal contraception reported that they had breastfed their last baby for 13.5+/-SD7.5 months while control women had done so for 14.1+/-SD9.4 months. The longest mean duration that women reported to have breastfed a previous infant was 19.5+/-SD9.6 months in the hormonal contraception group and 19.1+/-SD8.6 months in the control group.

A case-control study of stillbirths at the Port Moresby General Hospital.

From September 1995 to May 1997, 315 consecutive stillbirths and 315 randomly selected controls were studied at the Port Moresby General Hospital to determine the causes of the deaths, to describe the sociodemographic and reproductive characteristics of the mothers, and to see if there were any avoidable factors in the stillbirths and where the responsibility for them lay. 249 (79%) of the stillbirths were antepartum and 14% were intrapartum; the timing of death could not be determined in the remaining 21 (7%). 36% of the stillbirths were unexplained. The common identified causes were: syphilis (VDRL and TPHA positive) 10%, intrauterine growth restriction/placental insufficiency 9%, antepartum haemorrhage 9%, malaria 6%, major congenital abnormalities 6%, cord accidents 6%, pregnancy-induced hypertension 5% and acute intrapartum asphyxia 4%. Multiple logistic regression analysis showed a significant association between stillbirth and the following variables: husband's occupation unskilled, age over 35 years, poor antenatal attendance, a past history of stillbirth, syphilis and malaria. An avoidable factor was established in 41% of the cases; in 60% the responsibility for the avoidable factor lay with the patient and her relatives.

Antenatal haemoglobin profile at the Port Moresby General Hospital.

From 1 November 1995 to 10 April 1996, 1001 consecutive mothers who had attended the Port Moresby General Hospital (PMGH) antenatal clinic and were delivered in the Maternity Unit of the PMGH were surveyed for their antenatal haemoglobin (Hb) levels. One or more Hb results had been noted in the antenatal records of 997 subjects. The mean of the first Hb level for this sample was 10.6 +/- 1.72 g/dl. The first Hb level was below 10.0 g/dl in 33% of the 997 subjects. The dates were reliable in 777 subjects. The mean first Hb for this group was the same as for the total sample. A subgroup of 449 subjects with reliable dates and first Hb measurement at < or = 26 weeks gestation had a first Hb mean of 10.9 +/- 1.78 g/dl. Among those with reliable dates, 569 had two or more Hb measurements, the last being at > or = 34 weeks. In this subgroup, the mean of the last Hb was 11.1 +/- 1.60 g/dl. The first Hb was measured at < or = 26 weeks in 352 subjects in this subgroup. The means for the first and last Hb levels for this subset were 10.9 +/- 1.78 and 11.1 +/- 1.57 g/dl, respectively; the paired t test did not show any difference between the first and last Hb levels. For subjects in the total sample who had two or more Hb measurements, the mean for the lowest Hb level was 10.0 +/- 1.54; 45% had levels below 10.0 g/dl at some time during the pregnancy.

A case of factor V deficiency presenting as menorrhagia.

Factor V deficiency is a rare hereditary disorder. We report a patient with factor V deficiency who presented with menorrhagia and pelvic haematoma. The Haematology Department at the Royal Brisbane Hospital performed the definitive factor assays leading to the diagnosis. The challenges of her management were obtaining adequate supplies of factor V and her socioeconomic circumstances. The main future challenge will be the supervision of her pregnancies.

A survey of under-18 year old and 20-29 year old primigravidae delivered at the Port Moresby General Hospital: a comparative study of their sociodemographic and sexuality characteristics and contraceptive knowledge and experience.

From July 1992 to August 1993, 330 under-18 year old primigravidae (cases) and 330 randomly selected 20-29 year old primigravidae (controls) who were delivered at the Port Moresby General Hospital were sequentially studied, using a standardized, pretested, precoded questionnaire. In stepwise logistic regression analysis, significantly more of the cases had menarche at less than 15 years of age, learned before menarche that sex causes pregnancy, were of highland origin, were unemployed, or had partners who were unemployed; significantly fewer of the cases thought that one sexual act could cause pregnancy, had knowledge of or had ever used a family planning method, or had planned this pregnancy.

PIP: This study aims to identify factors (explanatory variables) which are associated with the risk of an adolescent becoming pregnant. From July 1992 to August 1993, 330 18 year old primigravidas (cases) and 330 randomly selected 20-29 year old primigravidas (controls), who were delivered at the Port Moresby General Hospital in Papua New Guinea, were sequentially studied. Trained research assistants administered a standard, pretested, precoded questionnaire. By using stepwise logistic regression analysis, it was revealed that significantly more of the cases had menarche at 15 years of age (81% vs. 49%), learned before menarche that sex causes pregnancy (51% vs. 32%), were of highland origin, were unemployed, or had partners who were unemployed. Moreover, significantly fewer of the cases thought that one sexual act could cause pregnancy, had knowledge of or had ever used a family planning method, or had planned their pregnancy.

A case-control study of primary caesarean section at the Port Moresby General Hospital, Papua New Guinea, to identify epidemiological predictors of abdominal delivery.

A retrospective study of 274 consecutive primary caesarean sections and 274 unmatched controls was carried out at Port Moresby General Hospital from January to December 1992. The primary caesarean section rate was 3.5%. Stepwise logistic regression analysis showed that primary caesarean section was significantly associated with maternal height of less than 150 cm; nulliparity; symphysis-fundal height of more than 38 cm at admission in labour; cervical dilatation of less than 4 cm at admission in labour; and the level of fetal head at admission in labour of 3/5 or higher.

A retrospective survey of patients with one previous caesarean section delivered at the Port Moresby General Hospital: a comparative study of those delivered vaginally and those delivered by repeat caesarean section.

We studied 510 patients in a retrospective, nonrandomized, comparative survey of vaginal births and repeat caesarean section after one primary caesarean section at the Port Moresby General Hospital. 478 (94%) were allowed a trial of scar (TOS). The most common indications for elective caesarean section in the other 32 patients were cephalopelvic disproportion (CPD) 31%, contracted pelvis 19% and preeclampsia 12.5%. In 41% of patients TOS was terminated by emergency caesarean section. Logistic regression analysis showed that the following were significantly associated with repeat caesarean section after TOS: parity of one, no vaginal birth after the primary caesarean section, narrow obstetric conjugate, birthweight of 2500 g or greater, short stature, high level of the head at admission to the labour ward and region of origin.

A case-control study of singleton low birthweight babies at the Port Moresby General Hospital.

A retrospective study of 432 consecutive singleton low birthweight babies and 432 unmatched controls was carried out at the Port Moresby General Hospital from January to December 1988. Of the 432 low birthweight babies 65% were preterm, 27% were light for gestational age, 6% were both preterm and light for gestational age and 2.5% could not be classified. The results of the analysis showed low birthweight to be significantly associated with the past delivery of a low birthweight infant, very young and elderly mothers, lack of antenatal care, poor family planning, hypertensive disease in pregnancy and intrauterine death. This study reveals that maternal education and improved antenatal care and family planning would ultimately reduce the incidence of low birthweight babies and perinatal mortality in Papua New Guinea.

Familial ovarian cancer: report of ovarian carcinoma in three sisters.

This is a report of ovarian carcinoma occurring in two sisters diagnosed almost at the same time, prompting prophylactic oophorectomy in a third sister. Histology of the overtly normal ovary in the third sister showed a focus of ovarian cancer. Discussion and a review of the literature suggest that any program designed to reduce the incidence of late-stage ovarian carcinoma should include the surveillance of family members of the index case, including the performance of prophylactic oophorectomy in the unaffected members of the family after they have completed their families.

A case-control study of meconium staining of amniotic fluid in labour at Port Moresby General Hospital to determine associated risk factors and perinatal outcome.

AIM: To identify sociodemographic and obstetric characteristics which could be used as markers for thick meconium staining of the amniotic fluid (MSAF) in labour. METHODS: The design was an unmatched case-control study. The setting was the Port Moresby General Hospital labour ward. The eligibility criteria were: patients with a singleton pregnancy, cephalic presentation and baby alive at the time of admission in labour. Cases were parturients who had MSAF during labour. The cases were sequentially enrolled according to the time of delivery recorded in the labour ward register. A control was a patient who did not have MSAF and who was the first to deliver after a case. Data were collected using an interviewer-administered questionnaire and patients' hospital records. RESULTS: Logistic regression analysis showed the following variables to have a positive significant association with MSAF: low social status, betelnut chewing, grand multiparity, past history of perinatal death and rupture of membranes to delivery interval. Preterm delivery was negatively associated with MSAF. Compared with the controls, the cases had a higher caesarean section rate; more of their babies were admitted to the Special Care Nursery (SCN); the mean stay of their babies in the SCN was longer; and the perinatal mortality was higher.

Prevalence of vaginal infections with bacterial vaginosis, Trichomonas vaginalis and Candida albicans among pregnant women at the Port Moresby General Hospital Antenatal Clinic.

A clinico-sociodemographic and microbiological survey was carried out at the Port Moresby General Hospital Antenatal Clinic to determine the prevalences of bacterial vaginosis, Trichomonas vaginalis and Candida albicans vaginal infections in pregnancy and to examine if the infections had any association with some suspected sociodemographic risk factors. The study was carried out between December 1990 and January 1991. Of 206 consecutive subjects surveyed, 79 (38%) had symptomatic infection. However, on speculum examination, abnormal discharge was seen in 188 (91%). 118 (57%) had microbiologically confirmed infection. The prevalences of the individual infections were T. vaginalis 19%, C. albicans 23% and bacterial vaginosis 23%. Combined infection, i.e. two infections occurring together in the same subject, was uncommon. None of the infections had an association with any of the sociodemographic characteristics studied. Of the 118 positive subjects, 52 (44%) complained of vaginal discharge and 55 (47%) complained of pruritus.

PIP: The prevalences of vaginal infections with Trichomonas vaginalis, bacterial vaginosis, and Candida albicans were investigated in 206 consecutive pregnant women presenting to Port Moresby (Papua New Guinea) General Hospital in 1990-91 for their first antenatal visit. Bacteriologic investigation identified Candida in 48 women (23%), T. vaginalis in 39 (19%), and bacterial vaginosis in 48 (23%). Overall, 118 women (57%) were bacteriologically positive for at least one infection. 79 (38%) of the infected women complained of a vaginal discharge and 78 (38%) reported vulvar irritation; however, vaginoscopy revealed abnormal discharge in 188 (91%) of women with an infection. Infection was not associated with gestational age or any of the sociodemographic variables examined (age, parity, ethnic group, residence, husband's education). The fact that the majority of pregnant women in this series had a vaginal infection is alarming in light of the hypothesized association of such infections with intra-amniotic infection, endometritis, premature rupture of the membranes, preterm labor or birth, and low birth weight. A randomized, controlled prospective study is needed to assess the extent to which, if any, these infections are related to the high perinatal morbidity and mortality from low birth weight at Port Moresby General Hospital.