Pre-eclampsia and gestational hypertension are less common in HIV infected women.

OBJECTIVE: To determine whether pre-eclampsia and gestational hypertension are less common in HIV infected women. METHODS: This prospective cohort study was performed in the Western Cape province of South Africa. HIV negative and positive pregnant women without chronic renal or chronic hypertensive disease were continuously recruited. During the study period HIV positive patients received either mono- or triple (HAART) antiretroviral therapy for prevention of vertical transmission or maternal care. Only routine clinical management was performed. The development of hypertensive disease during pregnancy was recorded. RESULTS: 1093 HIV positive and 1173 HIV negative cases were identified during pregnancy and evaluated again after delivery. Significantly fewer cases of pre-eclampsia n=35 (3.2%) were recorded in the HIV positive group than in the HIV negative group, n=57 (4.9%) (p=0.045; OR 0.65 95% CI 0.42-0.99). There were also significantly fewer cases of gestational hypertension recorded in the HIV positive group compared to the HIV negative group (p=0.026; OR 0.53 95% CI 0.30-0.94). Multiple logistic regression analysis confirmed the reductive effect of HIV on pre-eclampsia and gestational hypertension. CONCLUSION: Pre-eclampsia and gestational hypertension are less common in HIV infected women being managed with mono- or triple anti-retroviral therapy.

Early antiretroviral therapy improves neurodevelopmental outcomes in infants.

OBJECTIVES: To evaluate the effect of early versus deferred antiretroviral therapy (ART) on the neurodevelopment of infants from Cape Town participating in the Children with HIV Early Antiretroviral Therapy (CHER) trial. DESIGN: HIV-infected infants were randomized to early (<3 months) or deferred ART. HIV-uninfected infants (HIV-exposed and HIV-unexposed) provide background data. METHODS: Neurological examination and Griffiths Mental Development Scales (GMDS) were administered between 10-16 months of age by testers blind to HIV status and randomized allocation. Mean quotients were compared using paired Student's t-tests. RESULTS: Sixty-four infants on early ART and 26 on deferred ART (of potential 77 and 38 respectively on CHER trial) were assessed at median age 11 months (range 10-16). On the GMDS, all scores were lower in the deferred arm and the General Griffiths and Locomotor Scores were significantly lower: mean (SD) =100.1 (13.8) vs. 106.3 (10.6) P=0.02; and 88.9 (16.3) vs. 97.7 (12.5), P<0.01, respectively. Children with HIV who received early ART performed as well as children without HIV except on the Locomotor subscale. Both infected and uninfected mean GMDS scores were within the average range. CONCLUSION: Infants initiated on early ART have significantly better Locomotor and general scores on the GMDS at median age 11 months compared to infants on deferred ART, despite careful monitoring and ready access to ART in the latter.

Specific exercises to treat pregnancy-related low back pain in a South African population.

OBJECTIVE: To investigate the effect of an exercise program, including specific stabilizing exercises, on pain intensity and functional ability in women with pregnancy-related low back pain. METHODS: Fifty women between 16 and 24 weeks of pregnancy were recruited at Tygerberg and Paarl Hospitals, Western Cape, South Africa. Twenty-six women were randomized to a 10-week exercise program and 24 were randomized as controls. RESULTS: Overall, the most frequent type of back pain experienced was lumbar pain (36 [72.0%]). Pain intensity (P=0.76) and functional ability (P=0.29) were comparable between the groups on study entry. In the study group, there was a significant improvement in pain intensity (P<0.01) and an improvement in functional ability (P=0.06) at the end of the study. In the control group, there were no significant changes in pain intensity (P=0.89) or functional ability (P=0.70) at the end of the study. CONCLUSION: A specific exercise program decreased back pain intensity and increased functional ability during pregnancy in South African women with lumbar and pelvic girdle pain.

Prevalence and Risks of Asymptomatic Bacteriuria among HIV Positive Pregnant Women

The objective of the study was to determine whether the prevalence of asymptomatic bacteriuria (ASB) and subsequent complications are higher in HIV-positive than in HIV-negative pregnant women. A prospective controlled study of asymptomatic pregnant women was carried out. One hundred and twenty-five consecutive HIV-positive women and 247 HIV-negative controls were screened for asymptomatic bacteriuria. Treatment of positive cultures was by means of antibiotics as per protocol. Nine percent (n=11) of HIV-positive patients and 7.9 (n=19) of HIV-negative patients had positive urine cultures (p=0.68). Microorganisms were similar in both groups. The incidence of preterm labour was 6.7 in the HIV-positive cohort; versus 11.3 in HIV-negative control patients (p=0.17). The rate of prelabour rupture of membranes was significantly increased in HIV-positive patients compared to HIV-negative controls (17 HIV-positive versus 13 HIV-negative patients; 14.17 and 5.42; respectively; RR 2.615; 95 CI; 1.314-5.204). CD4+ cell count level

Evaluation of the use of umbilical artery Doppler flow studies and outcome of pregnancies at a secondary hospital.

OBJECTIVE: To investigate the use of a personal computer (PC)-based, continuous-wave Doppler machine by a trained midwife at a secondary hospital to assess umbilical artery flow velocity waveforms (FVW) in referred women. METHODS: Pregnant women referred for suspected poor fetal growth were evaluated from June 2002 through December 2004. The Umbiflow apparatus, consisting of a Pentium 3 PC with an ultrasound transducer plugged into the USB port and software, was used to analyze the FVW of the umbilical artery. Pregnancies in which the resistance index (RI) was <75(th) percentile (P75) were not further evaluated for fetal well-being unless the clinical condition of the mother changed. Pregnancies with an RI >or=P75 were followed up according to a specific protocol. Primary end points were intrauterine death and intrauterine growth restriction. RESULTS: A total of 572 singleton pregnancies were followed up. Significantly more infants were small-for-gestational-age when the RI was >P95 (55.6%) than those between P75 and P95 (41.2%) or P95, respectively. CONCLUSIONS: A normal Doppler FVW of the umbilical artery is less likely to be followed by perinatal death.

Early pre-eclampsia: what proportion of women qualify for expectant management and if not, why not?

OBJECTIVE: To determine what proportion of women with early pre-eclampsia qualify for expectant management and the magnitude of factors excluding this approach. STUDY DESIGN: A prospective case series with continuous data capture over one year at a tertiary referral centre. All women (n=169) with singleton pregnancies, presenting with early (> or =20 and <34 weeks' gestation) pre-eclampsia, were admitted, stabilised and evaluated. Major maternal or fetal complications at this stage were indications for delivery. However, when the pregnancy was otherwise stable, expectant management was commenced if the gestation was >or =24 weeks. Termination was offered from 20 to 23 weeks' gestation. RESULTS: Of the 169 women admitted, 82 (48.5%) were managed expectantly and 87 (51.5%) delivered after stabilisation and evaluation. Early fetal distress (32%) and major maternal complications (28%) were the most frequent reasons preventing expectant management. Ascites (18%) and HELLP syndrome (13%) ranked highest amongst the maternal complications. CONCLUSIONS: In this study, almost half of the women presenting with early onset pre-eclampsia qualified for expectant management. Early fetal distress was the most frequent reason preventing expectant management.

Luteal phase support in in vitro fertilization: meta-analysis of randomized trials.

OBJECTIVE: To determine if luteal phase support improves the pregnancy rate in in vitro fertilization (IVF) cycles. DESIGN: A meta-analysis of randomized trials of luteal phase support was carried out with the main outcome measure being the pregnancy rate per cycle. RESULTS: Fifty-nine trials were evaluated. Eighteen trials met the inclusion criteria. Five main themes were identified: human chorionic gonadotropin (hCG) versus progesterone; progesterone versus progesterone and hCG; progesterone versus placebo; hCG versus placebo, and hCG versus progesterone versus no support. CONCLUSION: Luteal phase support is definitely indicated in IVF treatment cycles. This meta-analysis favored hCG above progesterone as luteal phase support with respect to pregnancy rates. Further prospective randomized trials are needed to determine a definite consensus with respect to the duration of luteal phase support in IVF cycles.

Early onset severe pre-eclampsia: expectant management at a secondary hospital in close association with a tertiary institution.

OBJECTIVES: Early onset severe pre-eclampsia is ideally managed in a tertiary setting. We investigated the possibility of safe management at secondary level, in close co-operation with the tertiary centre. DESIGN: Prospective case series over 39 months. SETTING: Secondary referral centre. POPULATION: All women (n= 131) between 24 and 34 weeks of gestation with severe pre-eclampsia, where both mother and fetus were otherwise stable. METHODS: After admission, frequent intensive but non-invasive monitoring of mother and fetus was performed. Women were delivered on achieving 34 weeks, or if fetal distress or major maternal complications developed. Transfer to the tertiary centre was individualised. MAIN OUTCOME MEASURES: Prolongation of gestation, maternal complications, perinatal outcome and number of tertiary referrals. RESULTS: Most women [n= 116 (88.5%)] were managed entirely at the secondary hospital. Major maternal complications occurred in 44 (33.6%) cases with placental abruption (22.9%) the most common. One maternal death occurred and two women required intensive care admission. A mean of 11.6 days was gained before delivery with the mean delivery gestation being 31.8 weeks. The most frequent reason for delivery was fetal distress (55.2%). There were four intrauterine deaths. The perinatal mortality rate (> or =1000 g) was 44.4/1000, and the early neonatal mortality rate (> or =500 g) was 30.5/1000. CONCLUSIONS: The maternal and perinatal outcomes are comparable to those achieved by other tertiary units. This model of expectant management of early onset, severe pre-eclampsia is encouraging but requires close co-operation between secondary and tertiary institutions. Referrals to the tertiary centre were optimised, reducing their workload and costs, and patients were managed closer to their communities.

Are domestic violence and the excessive use of alcohol risk factors for preterm birth?

Violence has been associated with adverse pregnancy outcome, which led us to determine whether patients who deliver preterm, experience more domestic violence than those who deliver at term. Two groups of patients were assessed, a preterm labour group and a low-risk group.A total of 229 patients were interviewed: 99 in the low-risk (LR) group and 130 in the preterm labour (PTL) group. The PTL group experienced significantly more violence throughout their lives than the LR group. Experiences of violence within the last year or during the pregnancy were also higher for the PTL group. This group smoked significantly more cigarettes per day, used more alcohol, and had a higher incidence of syphilis than the LR group. Violence alone does not seem to cause PTL directly, but is part of a low socioeconomic lifestyle. The fact that alcohol-use is so high among these women needs to be addressed and the need for education on values and respect, family planning use, and low-risk sexual behaviour is once again challenged.