Audit of severe acute morbidity in hypertensive pregnancies in a developing country.

The aim of this study was to establish a population-based incidence of severe acute maternal morbidity (SAMM) in hypertensive pregnancies and to assess if substandard care was unique to cases of SAMM and mortality or whether it was apparent in uncomplicated pregnancies as well. The population-based incidence of hypertension was 12%. Using defined criteria for SAMM, the incidence of SAMM was 3/1000 deliveries. The MMR was 42/100000 deliveries, i.e. SAMM is seven times greater than the mortality. Substandard care was similar in cases of SAMM and mortality and uncomplicated hypertensive patients. Audit of SAMM is informative, can be conducted more frequently, and in small sample population groups. It also allows interviews of patients, hence problems of inefficient documentation is obviated.

A double-blind randomised controlled trial of continuous oxygen therapy for compromised fetuses.

OBJECTIVE: To investigate the effect of chronic oxygen therapy in fetuses with absent end diastolic flow in the umbilical artery assessed by doppler analysis at 24-30 weeks of gestation. DESIGN: A double-blind, randomised control trial was performed with patients blindly allocated to receive humidified oxygen or humidified air. SETTING: A tertiary referral hospital in South Africa. PARTICIPANTS: Thirty-two women who presented between 24 and 30 weeks of gestation with a confirmed finding of absent end diastolic flow in the umbilical artery. METHODS: After randomisation patients were allocated to receive a 40% mixture of humidified oxygen or humidified air from uniform coloured gas cylinders which were marked either 'a' or 'b' All women received betamethasone from 27 weeks of gestation on a weekly basis. Cardiotocographs were used from 28 weeks of gestation; after 28 weeks of gestation an amniocentesis was considered to confirm fetal maturity. Women were expected to breath the allocated gas continuously apart from meals and visits to the toilet. MAIN OUTCOME MEASURES: Survival of the fetus was the main outcome measure with secondary outcome measures documenting improvement in the fetal condition in utero. RESULTS: There were 16 women randomised to receive oxygen and 16 to receive air. There were nine survivors in the oxygen group (56.3%) and six in the air group (37.5%) (relative risk 1.5, 95% confidence interval 0.7-3.2). There was a nonsignificant increase in mean birthweight in the oxygen group (858.3 grammes vs 774.4 grammes) and a nonsignificant increase in mean duration of treatment in the oxygen group (12.8 days vs 10.4 days). CONCLUSION: This study did not demonstrate that chronic oxygen therapy provides any benefits to compromised fetuses between 24 and 30 weeks of gestation. Larger studies with sufficient power are necessary to assess whether oxygen therapy can reduce perinatal mortality by a clinically useful amount in this group of patients.

Care of the critically ill parturient: oliguria and renal failure.

The incidence of acute renal failure in pregnancy has decreased. This decrease is less marked in developing countries in which resources are more scarce. The clinical diagnosis of acute renal failure is crude due to the variability of clinical signs and the late occurrence of basic biochemical abnormalities. Obstetric and gynaecological diseases are found among the traditional pre-renal, intra-renal and post-renal causes of acute renal failure. The cornerstone of management is the identification of high-risk cases and the prevention of acute renal failure by maintaining intravascular volume. The evidence for the efficacy of other prophylactic medical interventions, such as the use of loop diuretics, mannitol, low-dose dopamine and others, is poor. Management of established acute renal failure includes restoration of intravascular volume, treatment of any reversible causes, especially pregnancy complications such as pre-eclampsia, strict fluid balance and correction of any electrolyte abnormality or metabolic acidosis. Dialysis is a supportive measure until the kidneys recover.

Severe acute maternal morbidity: a pilot study of a definition for a near-miss.

OBJECTIVE: To test the application of a clinical definition of severe acute maternal morbidity. DESIGN: A one-year prospective descriptive multi-centre study. SETTING: Kalafong and Pretoria Academic hospitals, catering for the delivery of indigent women in the Pretoria Health Region. METHODS: A 'near-miss' describes a patient with an acute organ system dysfunction, which if not treated appropriately, could result in death. The case notes of women fitting this definition and all maternal deaths were analysed and compared. OUTCOME MEASURE: Determine the primary obstetric factors and the organ systems that failed. Identification of episodes of sub-standard care and missed opportunities. Results One hundred and forty-seven near misses and 30 maternal deaths were identified. The commonest reasons for a near-miss were: emergency hysterectomy in 42 women (29%); severe hypotension in 40 (27%); and pulmonary oedema in 24 (16%). The most common initiating obstetric conditions were hypertension in 38 women (26%); haemorrhage in 38 (26%); and abortion or puerperal sepsis in 29 (20%). The primary obstetric factors amongst the maternal deaths were: hypertension (33%); sepsis (27%); and maternal medical diseases (17%) in 10, 8 and 5 women respectively. Sub-standard care was identified in 82 cases. Breakdown in the health care administration was identified in 33, and patient-orientated missed opportunities on 34 occasions. CONCLUSION: The definition of severe acute maternal morbidity identified nearly five times as many cases as maternal death. This definition allows for an effective audit system of maternal care because it is clinically based, the definition is robust and the cases identified reflect the pattern of maternal death.

Low dose dopamine in postpartum pre-eclamptic women with oliguria: a double-blind, placebo controlled, randomised trial.

OBJECTIVE: To assess the effect of low dose dopamine on the urine output in postpartum pre-eclamptic or eclamptic women with oliguria. DESIGN: A double blind, randomised controlled study. SETTING: The high care area of the labour ward in a teaching hospital. SAMPLE: Forty postpartum pre-eclamptic women with oliguria, defined as < 30 mL/hour, who have not responded to a 300 mL crystalloid fluid challenge. INTERVENTION: Dopamine was infused at a rate of 1 to 5 microg/kg per minute, or sterile water was given as placebo in the same dilution. MAIN OUTCOME MEASURE: Urine output, blood pressure and pulse was measured for six hours before and for six hours after the intervention. RESULTS: Women who received dopamine (344 mL over 6 hours) showed a clinically and statistically significant (P = 0.0014, Mann-Whitney U test) higher median urine output compared with those receiving placebo (135 mL over 6 hours) for the duration of therapy. The respective 95% confidence intervals were 212.3 to 712.7 mL compared with 73.8 to 244.7 mL. No differences in blood pressure or pulse were found between the two groups. CONCLUSIONS: The use of low dose dopamine in a labour setting improved urine output in postpartum pre-eclamptic women with oliguria who had not responded to a single fluid challenge without a detrimental effect on the blood pressure or pulse.