Patients' experiences of termination of pregnancy at a regional hospital in Durban, South Africa.

BACKGROUND: Safe and effective termination of pregnancy (ToP) services have helped to resolve the uncertainty that surrounds unwantedpregnancies globally and in South Africa (SA). It is important to determine the demographic profile of women requesting ToP and to assessthe reasons for ToP and the beliefs and experiences of women seeking these services in order to improve service delivery. OBJECTIVES: To determine the sociodemographic profile and emotional and psychological experiences of women undergoing ToP at aregional hospital in Durban, SA. METHODS: The study population consisted of women seeking either medical or surgical ToP at the Addington Hospital ToP clinic from Juneto August 2021. The participants were requested to complete a structured self-reporting questionnaire on their sociodemographics, theirawareness of, attitude to and knowledge of ToP, and their reasons for seeking ToP services, as well as contraception method and use. Thequestionnaire also captured their experience after the ToP was completed. RESULTS: Of the 246 participants, the majority (92.3%) were aged 16 - 35 years, with 62.6% having little or no income and dependent ontheir family or partner for financial support. Most of the participants (73.2%) were parous and had secondary education and above (94.3%).Furthermore, 59.0% of the participants indicated they were not on any form of contraception before becoming pregnant, even though 70.3%of them were single. The most cited reasons for ToP were lack of finance (37.5%), schooling (33.9%), and not feeling ready to be a parent(20.0%). Although some participants (35.7%) were fearful of ToP, most of them (78.0%) reported feeling relieved after the procedure. CONCLUSION: Unemployment and financial dependency appeared to be common reasons for seeking ToP in our study population. Most ofthe women were single and many had not used any contraception prior to the pregnancy.

Influence of HIV and its treatment on hypertensive disorders of pregnancy in women from a low- to middle-income country.

OBJECTIVE: To establish a potential relationship between hypertensive disorders of pregnancy (HDP) and HIV infection. METHODS: This cross-sectional observational study involving 300 women with HDP was undertaken from September 2018 to February 2019 in a regional hospital in Durban, South Africa, a setting with a background HIV prevalence of 45% among pregnant women. All women with new-onset elevation of blood pressure after the 20th week of pregnancy were enrolled and, following informed consent, the relevant information was extracted from their files. RESULTS: Of the 300 women with HDP, the HIV prevalence was 30%, compared with the historical seroprevalence of 45% within the hospital (P = 0.028). For all categories of HDP, there were fewer primigravid women among women living with HIV (WLHIV), compared with those uninfected (30% vs 50.2%, respectively; P = 0.001). HDP developed later in gestation in WLHIV compared with uninfected women (32.6 weeks vs 34 weeks, respectively; P = 0.023), however, there were significant maternal complications of abruption and elevated liver enzymes among WLHIV (P = 0.02 and P = 0.014, respectively). Despite this, the perinatal outcomes were similar in both groups. CONCLUSION: HIV or its treatment seems to have a protective effect in the development of HDP; however, the complications of HDP may be significant in WLHIV receiving treatment.

The impact of the duration of HAART on cytokine profiles in pregnancy.

OBJECTIVE: To determine the cytokine profile of HIV infected women treated with highly active anti-retroviral therapy (HAART) of variable duration in pregnancy. METHODS: HIV infected women were enrolled at a large tertiary hospital in Durban, South Africa in their antenatal period and stratified into those that initiated HAART before pregnancy (pre-pregnancy HAART or PPH group) and those who initiated HAART during pregnancy (in-pregnancy HAART or IPH group). These were compared with HIV negative women (HN group), matched for gestational age at the time of enrolment. Serum was obtained and Th1 and Th2 cytokines expression determined using the Bio-Plex Pro™ Human Cytokine Treg Panels. RESULTS: The overall cytokine profile of the cohort was pro-inflammatory as a result of significant IL-6 and TNF alpha expression. The anti-inflammatory markers (i.e. Th2 cytokines, namely IL4 and IL10) were poorly expressed by the whole cohort, with IL 4 seen almost exclusively in the IPH group, thus counter-balancing the predominantly pro-inflammatory milieu only in this group. PPH group had a pro-inflammatory milieu comparable to the HN control. IL 6 was the predominant cytokine in all groups, and as expected, it increased with advancing gestation in all the groups. This highly pro-inflammatory milieu was unexpected and needs further review CONCLUSION: Long use of HAART suppresses the anti-inflammatory markers previously reported to be conducive for the wellbeing of pregnancy. This effect needs further review as it was similarly observed in our HIV uninfected controls.

Maternal and obstetric complications among HIV-infected women treated with highly active antiretroviral treatment at a Regional Hospital in Durban, South Africa.

INTRODUCTION: HIV is the leading cause of maternal deaths in resource-poor countries. The use of highly active antiretroviral treatment (HAART) has been shown to almost eliminate vertical transmission and improve maternal health outcomes. Its effect on direct obstetric conditions has not been well documented. METHODS: We conducted a retrospective study of women who delivered at a regional hospital from April 1, 2011, to April 30, 2014. We employed a stratified random selection, where the first 50 files recorded in the birth register during each calendar month were chosen, at a ratio of one HIV uninfected for every 4 infected women. RESULTS: We analyzed files belonging to 302 HIV-uninfected women and 1159 HIV-infected women. The latter were further subdivided into those who used zidovudine, n = 424; those who initiated HAART prepregnancy, n = 312; and those who initiated in-pregnancy HAART, n = 423. We found that despite the use of HAART, HIV-infected women were at increased risk of both respiratory and lower genital tract infections (P = 0.009 and 0.001 respectively), compared to HIV-uninfected women. The women receiving HAART before pregnancy had an increased risk of preterm births (P = 0.004), and poor perinatal outcomes (P = 0.002); however, postpartum complications were reduced (P = 0.023). There was a trend toward an increased risk of preeclampsia (P = 0.064). CONCLUSION: The initiation of HAART before pregnancy reduces the frequency of postpartum complications. However, compared to HIV-negative women, women receiving HAART prepregnancy remained at risk of infectious morbidity, had poor perinatal outcomes, and may also be at an increased risk of preeclampsia.

Thrombocytopenia during pregnancy in women with HIV infection receiving no treatment.

UNLABELLED:  Background. Thrombocytopenia (TCP) complicates 5 - 8% of pregnancies. Most cases of TCP are gestational, and the condition is usually mild and occurs in the latter part of pregnancy. Apart from pregnancy-associated medical complications such as pre-eclampsia, HIV infection is a recognised cause of TCP, and a relatively high prevalence of TCP during pregnancy would be expected in a setting with a high antenatal seroprevalence of HIV. METHODS: This was a sub-analysis of the data from a prospective trial in which the incidence of postpartum sepsis in HIV-infected women was compared with that in HIV-uninfected women. Women who were considered at low risk and eligible for vaginal delivery were recruited at 36 weeks' gestation, and followed up for 6 weeks after delivery. Full blood counts and CD4counts of HIV-infected women were obtained at baseline and repeated 6 weeks after delivery. RESULTS: The prevalence of TCP was 5.3% during pregnancy and 1.2% 6 weeks after delivery. The prevalence was similar among HIV-infected (6.0%) and HIV-uninfected women (4.7%) (p=0.292). Among the HIV-infected women, who were not receiving antiretroviral therapy (mean CD4 cell count of 453 cells/µL), there was no significant association between immunosuppression and the severity of TCP. CONCLUSIONS: Most of the TCP seen during pregnancy is of the gestational variety, and in this study HIV infection did not increase its prevalence or its severity.

Pathogenic lower genital tract organisms in HIV-infected and uninfected women, and their association with postpartum infectious morbidity.

OBJECTIVES: To determine the prevalence of vaginal pathogens during pregnancy and their impact on postpartum infectious morbidity among antiretroviral-naïve HIV-infected, and HIV-uninfected, women. METHODS: Vaginal swabs were obtained during early labour by speculum examination prior to digital vaginal examination, and sent for microscopy and culture. Women were assessed for infectious complications within 24 - 72 hours of delivery, and up to 2 weeks postpartum. RESULTS: Laboratory results were available for 801 women who delivered vaginally (418 HIV infected and 383 uninfected). The baseline characteristics of the two groups were comparable, and the median CD4 count for HIV-infected women (N=391) was 416/µl. Fifty-five per cent (54.8%) of women had positive cultures (439/801), more among those who were HIV infected, than uninfected (60% v. 49.1%, p=0.002). Women with positive cultures had slightly higher rates of infectious morbidity than those without (20.5% v. 15.2%, p=0.052). Trichomonas vaginalis and group B streptococcus were significantly associated with sepsis (p=0.023 and <0.001, respectively), whereas the presence of Candida species seemed to be protective (relative risk 0.69, p=0.014). CONCLUSION: The study shows that a high proportion of pregnant women have pathogenic organisms in the lower genital tract that are associated with development of postpartum infections morbidity.

Determinants of postpartum infectious complications among HIV uninfected and antiretroviral naïve-HIV infected women following vaginal delivery: a prospective cohort study.

OBJECTIVE: To determine the incidence rate of postpartum infectious morbidity among HIV uninfected women compared to antiretroviral naïve-HIV infected women who were eligible for vaginal delivery. STUDY DESIGN: A nested study was conducted within a large prospective trial in which HIV infected women eligible for vaginal delivery at term were compared with HIV uninfected women. Women were reviewed within 72 h post delivery, at 1, 2 and 6 weeks for clinical signs of puerperal infection. RESULTS: 241 HIV infected women were compared with 427 HIV uninfected controls. Both groups were comparable in terms of baseline parameters. The infectious morbidity rate was similar between the HIV infected and uninfected women (p=0.977). Factors which significantly increased puerperal infections in both groups were the presence of an episiotomy, p<0.001, the number of vaginal examinations after rupture of amniotic membranes, p=0.026, and a CD4 count of <200 micro/L, p=0.017 in the HIV infected group. CONCLUSION: There was no difference in postpartum infections amongst HIV infected compared to uninfected women, but an episiotomy was associated with a 2-fold increased risk of infectious morbidity.

Changing patterns of maternal mortality (HIV/AIDS related) in poor countries.

Maternal mortality is greatest in poor countries and it is in exactly these countries that the human immunodeficiency virus (HIV) poses an added challenge in attaining the Millennium Development Goals. The prevalence of HIV infection in many poor countries continues to rise. South Africa is an example of how some of the challenges can be addressed. Recommendations by the South African National Committee on the Confidential Enquiry into Maternal Deaths stressed the importance of addressing the antenatal, intrapartum and postpartum care of women, laying emphasis on the need for societal support, including nutritional and emotional support, reproductive health services including contraception, provider-initiated counselling and testing (PICT) and prevention. Antenatal care needs to be targeted for support and early intervention when abnormalities are detected, including the initiation of highly active antiretroviral therapy when necessary. Intrapartum care needs to be conducted in a hygienic environment with access to operative delivery. More attention needs to be paid to postpartum care because most women tend to succumb to puerperal sepsis. Ethical principles must be upheld when managing women with HIV infection.

Prophylactic antibiotics for the prevention of postpartum infectious morbidity in women infected with human immunodeficiency virus: a randomized controlled trial.

OBJECTIVE: The purpose of this study was to determine the effect of intrapartum prophylactic antibiotics in the prevention of postpartum sepsis in laboring women who were infected with HIV. STUDY DESIGN: In a double-blind, randomized trial that was conducted in Durban (South Africa), pregnant women who were infected with HIV in whom vaginal delivery was anticipated were randomized to receive either a single dose of cefoxitin (2 g) or placebo intrapartum. Signs of sepsis were evaluated within 72 hours and at 1 and 2 weeks postpartum. RESULTS: Of the 424 women who were enrolled, 213 women received cefoxitin, and 211 women received placebo. Both groups were comparable in all baseline parameters. The overall sepsis rate was 19% (40/211 women) in the placebo group and 16.9% (36/213 women) in the cefoxitin group (P = .581). There was a 53% reduction in risk of postpartum endometritis in the cefoxitin group (95% confidence interval, 0.24-0.9). CONCLUSION: The use of prophylactic intrapartum cefoxitin in HIV-infected women reduces the risk of postpartum endometritis.