Randomized trial to compare acceptability of magnesium sulphate administration for preeclampsia and eclampsia: Springfusor pump versus standard of care.

INTRODUCTION: In low-resource settings, magnesium sulphate (MgSO4) for preeclampsia is administered majorly through an injection into the gluteal muscles 4-hourly for 24 hours. The repeated injections are very painful and may lead to infection, abscess formation, and reduced compliance. OBJECTIVE: To determine the acceptability of Springfusor® pump for the administration of Magnesium Sulphate in preeclampsia and eclampsia. DESIGN: Randomized Open Label Clinical Trial. METHODS: The study was conducted at Kawempe National Referral Hospital. Eligible women had a systolic blood pressure of ≥140mmHg and or diastolic blood pressure >90mmHg, proteinuria ≥+1, and the physician's decision to start on MgSO4. Four-hundred-ninety-six participants were randomized to a Springfusor® pump group (n = 248) or control (standard of care) (n = 248) administration of MgSO4. Intervention group had a loading dose (4gm of 50% MgSO4 intravenously over 20 minutes) and maintenance therapy (1gm of 50% MgSO4 intravenously per hour for 24 hours) administered using the Springfusor®. The standard of care (SOC) group received a loading dose of 4gm of 20% MgSO4 IV over 15-20 minutes, followed by 10gm of 50% MgSO4 intramuscular (5gm in each buttock) and a maintenance dose of 5gm of 50% MgSO4 was administered IM every 4 hours for 24 hours. Both arms received the rest of the care for preeclampsia/eclampsia as per the hospital guidelines. Acceptability of the method of administration was assessed using a Likert scale (1-5; 1 and 2: acceptable and 3-5: unacceptable). Pain at the site of MgSO4 administration was assessed using a Visual Analogue Scale 1-7, (1 minimal pain and 7 worst pain). Comparisons were assessed with the Chi-square test, Mann Whitney-Wilcoxon test, and Students' t-test. RESULTS: Intervention arm; was more acceptable than the standard of care arm, (95.3% vs70.3%; p<0.001), had a lower median pain score, (2(CI: 2-2), vs 4(CI: 4-5) p<0.001), and fewer side effects. Maternal mortality was comparable between groups (0.8% in the intervention arm vs 1.2% in the IM arm). TRIAL REGISTRATION: Trial No PACTR201712002887266 (https://pactr.samrc.ac.za/).

Maternal and umbilical cord blood lactate for predicting perinatal death: a secondary analysis of data from a randomized controlled trial.

BACKGROUND: In high resource settings, lactate and pH levels measured from fetal scalp and umbilical cord blood are widely used as predictors of perinatal mortality. However, the same is not true in low resource settings, where much of perinatal mortality occurs. The scalability of this practice has been hindered by difficulty in collecting fetal scalp and umbilical blood sample. Little is known about the use of alternatives such as maternal blood, which is easier and safer to obtain. Therefore, we aimed to compare maternal and umbilical cord blood lactate levels for predicting perinatal deaths. METHODS: This was secondary analysis of data from a randomized controlled trial assessing the effect of sodium bicarbonate on maternal and perinatal outcomes among women with obstructed labour at Mbale regional referral hospital in Eastern Uganda. Lactate concentration in maternal capillary, myometrial, umbilical venous and arterial blood was measured at the bedside using a lactate Pro 2 device (Akray, Japan Shiga) upon diagnosis of obstructed labour. We constructed Receiver Operating Characteristic curves to compare the predictive ability of maternal and umbilical cord lactate and the optimal cutoffs calculated basing on the maximal Youden and Liu indices. RESULTS: Perinatal mortality risk was: 102.2 deaths per 1,000 live births: 95% CI (78.1-130.6). The areas under the ROC curves were 0.86 for umbilical arterial lactate, 0.71 for umbilical venous lactate, and 0.65 for myometrial lactate, 0.59 for maternal lactate baseline, and 0.65 at1hr after administration of bicarbonate. The optimal cutoffs for predicting perinatal death were 15 0.85 mmol/L for umbilical arterial lactate, 10.15mmol/L for umbilical venous lactate, 8.75mmol/L for myometrial lactate, and 3.95mmol/L for maternal lactate at recruitment and 7.35mmol/L after 1 h. CONCLUSION: Maternal lactate was a poor predictor of perinatal death, but umbilical artery lactate has a high predictive value. There is need for future studies on the utility of amniotic fluid in predicting intrapartum perinatal deaths.

Prediction of pre-eclampsia at St. Mary's hospital lacor, a low-resource setting in northern Uganda, a prospective cohort study.

BACKGROUND: Pre-eclampsia is the second leading cause of maternal death in Uganda. However, mothers report to the hospitals late due to health care challenges. Therefore, we developed and validated the prediction models for prenatal screening for pre-eclampsia. METHODS: This was a prospective cohort study at St. Mary's hospital lacor in Gulu city. We included 1,004 pregnant mothers screened at 16-24 weeks (using maternal history, physical examination, uterine artery Doppler indices, and blood tests), followed up, and delivered. We built models in RStudio. Because the incidence of pre-eclampsia was low (4.3%), we generated synthetic balanced data using the ROSE (Random Over and under Sampling Examples) package in RStudio by over-sampling pre-eclampsia and under-sampling non-preeclampsia. As a result, we got 383 (48.8%) and 399 (51.2%) for pre-eclampsia and non-preeclampsia, respectively. Finally, we evaluated the actual model performance against the ROSE-derived synthetic dataset using K-fold cross-validation in RStudio. RESULTS: Maternal history of pre-eclampsia (adjusted odds ratio (aOR) = 32.75, 95% confidence intervals (CI) 6.59-182.05, p = 0.000), serum alkaline phosphatase(ALP) < 98 IU/L (aOR = 7.14, 95% CI 1.76-24.45, p = 0.003), diastolic hypertension ≥ 90 mmHg (aOR = 4.90, 95% CI 1.15-18.01, p = 0.022), bilateral end diastolic notch (aOR = 4.54, 95% CI 1.65-12.20, p = 0.003) and body mass index of ≥ 26.56 kg/m2 (aOR = 3.86, 95% CI 1.25-14.15, p = 0.027) were independent risk factors for pre-eclampsia. Maternal age ≥ 35 years (aOR = 3.88, 95% CI 0.94-15.44, p = 0.056), nulliparity (aOR = 4.25, 95% CI 1.08-20.18, p = 0.051) and white blood cell count ≥ 11,000 (aOR = 8.43, 95% CI 0.92-70.62, p = 0.050) may be risk factors for pre-eclampsia, and lymphocyte count of 800 - 4000 cells/microliter (aOR = 0.29, 95% CI 0.08-1.22, p = 0.074) may be protective against pre-eclampsia. A combination of all the above variables predicted pre-eclampsia with 77.0% accuracy, 80.4% sensitivity, 73.6% specificity, and 84.9% area under the curve (AUC). CONCLUSION: The predictors of pre-eclampsia were maternal age ≥ 35 years, nulliparity, maternal history of pre-eclampsia, body mass index, diastolic pressure, white blood cell count, lymphocyte count, serum ALP and end-diastolic notch of the uterine arteries. This prediction model can predict pre-eclampsia in prenatal clinics with 77% accuracy.

Postpartum resolution of hypertension, proteinuria and acute kidney injury among women with preeclampsia and severe features at Mulago National Referral Hospital, Uganda: a cohort study.

Background: The resolution of hypertension, proteinuria and AKI postpartum among women with preeclampsia is not well documented in Uganda. Objective: To determine the time to resolution of hypertension, proteinuria and AKI postpartum until 6 weeks among women with preeclampsia in Mulago Hospital, Uganda. Methods: Between August 2017 and April 2018, we measured blood pressure, urine protein and serum creatinine on days 1,7,21 and 42 postpartum among 86 women with preeclampsia. The primary outcomes were time to the resolution of hypertension, proteinuria and AKI. We fitted accelerated failure models using Stata 17's stintreg. command with a log normal distribution and obtained time ratios of selected exposures on time to resolution of hypertension, proteinuria and AKI intervals. Results: The median time to resolution of hypertension, proteinuria and AKI was seven (7) days (Inter quartile range, IQR 1-21). The time to resolution of hypertension among primiparous women was 3.5 times that of multiparous women [TR 3.5, 95%CI 1.1, 11.3]. No differences were observed in resolution of hypertension, proteinuria and acute kidney injury. Conclusion: The time to resolution of hypertension, proteinuria and AKI was seven days. We recommend larger studies with longer follow-up beyond six-weeks postpartum to inform revision of our guidelines.

Prevalence and factors associated with lumbopelvic pain among pregnant women in their third trimester: a cross-sectional study.

Introduction: pregnancy related lumbopelvic pain, which refers to low back pain and pelvic girdle pain, is a common musculoskeletal disorder affecting quality of life. The purpose of this study was to establish the prevalence and the factors associated with lumbopelvic pain among pregnant women in their third trimester. Methods: four hundred and nineteen pregnant women were included in this institutional-based cross-sectional study. The study was carried out from October 2018 to March 2019 at Kawempe national referral hospital in Uganda. Pregnant women in the third trimester participated in the study. Pregnant women with preexisting backache, a fracture or surgery to the back, hip or pelvic area in the preceding 12 months were excluded. Lumbopelvic pain was defined as low back pain and pelvic girdle pain. Bivariate and multivariable logistic regression were carried out to establish the factors associated with lumbopelvic pain. The presence of lumbopelvic pain was assessed for and diagnosed using the illustrations in the pelvic girdle questionnaire. Results: the prevalence of pregnancy related lumbopelvic pain was 46% (95% CI: 40.8-50.4). Most women who had pregnancy related lumbopelvic pain experienced lumbar pain. The factors independently associated with pregnancy related lumbopelvic pain (PLPP) were being HIV sero positive [adjusted odds ratio (AOR) 2.25, 95% CI: 1.17-4.35] and having no monthly income (AOR 0.53, 95% CI: 0.30-0.94). Conclusion: in this study, PLPP is common in women attending antenatal clinic in their third trimester. The factors associated with PLPP were being HIV positive and having no income. In future pregnant women who come for antenatal care with pregnancy related lumbopelvic pain should be given appropriate advice and support.

Prediction of stillbirth low resource setting in Northern Uganda.

BACKGROUND: Women of Afro-Caribbean and Asian origin are more at risk of stillbirths. However, there are limited tools built for risk-prediction models for stillbirth within sub-Saharan Africa. Therefore, we examined the predictors for stillbirth in low resource setting in Northern Uganda. METHODS: Prospective cohort study at St. Mary's hospital Lacor in Northern Uganda. Using Yamane's 1967 formula for calculating sample size for cohort studies using finite population size, the required sample size was 379 mothers. We doubled the number (to > 758) to cater for loss to follow up, miscarriages, and clients opting out of the study during the follow-up period. Recruited 1,285 pregnant mothers at 16-24 weeks, excluded those with lethal congenital anomalies diagnosed on ultrasound. Their history, physical findings, blood tests and uterine artery Doppler indices were taken, and the mothers were encouraged to continue with routine prenatal care until the time for delivery. While in the delivery ward, they were followed up in labour until delivery by the research team. The primary outcome was stillbirth 24 + weeks with no signs of life. Built models in RStudio. Since the data was imbalanced with low stillbirth rate, used ROSE package to over-sample stillbirths and under-sample live-births to balance the data. We cross-validated the models with the ROSE-derived data using K (10)-fold cross-validation and obtained the area under curve (AUC) with accuracy, sensitivity and specificity. RESULTS: The incidence of stillbirth was 2.5%. Predictors of stillbirth were history of abortion (aOR = 3.07, 95% CI 1.11-8.05, p = 0.0243), bilateral end-diastolic notch (aOR = 3.51, 95% CI 1.13-9.92, p = 0.0209), personal history of preeclampsia (aOR = 5.18, 95% CI 0.60-30.66, p = 0.0916), and haemoglobin 9.5 - 12.1 g/dL (aOR = 0.33, 95% CI 0.11-0.93, p = 0.0375). The models' AUC was 75.0% with 68.1% accuracy, 69.1% sensitivity and 67.1% specificity. CONCLUSION: Risk factors for stillbirth include history of abortion and bilateral end-diastolic notch, while haemoglobin of 9.5-12.1 g/dL is protective.

Continuum of care for maternal health in Uganda: A national cross-sectional study.

INTRODUCTION: A continuum of maternal care approach can reduce gaps and missed opportunities experienced by women and newborns. We determined the level of coverage and factors associated with the continuum of maternal care in Uganda. METHODS: We used weighted data from the Uganda Demographic and Health Survey (UDHS) 2016. We included 10,152 women aged 15 to 49 years, who had had a live birth within five years preceding the survey. Stratified two-stage cluster sampling design was used to select participants. Continuum of maternal care was considered when a woman had at least four antenatal care (ANC) visits, had delivered in a health facility and they had at least one postnatal check-up within six weeks. We conducted multivariable logistic regression analysis to determine factors associated with completion of the continuum of maternal care using SPSS version 25. RESULTS: The level of coverage of complete continuum of maternal care was 10.7% (1,091) (95% CI: 10.0-11.2). About 59.9% (6,080) (95% CI: 59.0-60.8) had four or more antenatal visits while 76.6% (7,780) (95% CI: 75.8-77.5) delivered in a health facility and 22.5% (2,280) (95% CI: 21.5-23.2) attended at least one postnatal care visit within six weeks. The following factors were associated with continuum of maternal care; initiating ANC in the first trimester (AOR 1.49, 95% CI: 1.23-1.79), having secondary level of education (AOR 1.60, 95% CI: 1.15-2.22) and tertiary level of education (AOR 2.08 95% CI: 1.38-3.13) compared to no formal education, being resident in Central Uganda (AOR 1.44, 95% CI:1.11-1.89), Northern Uganda (AOR 1.35, 95% CI: 1.06-1.71) and Western Uganda (AOR 0.61, 95% CI: 0.45-0.82) compared to Eastern Uganda, and exposure to newspapers and magazines. CONCLUSION: The level of coverage of the complete continuum of maternal care was low and varied across regions. It was associated with easily modifiable factors such as early initiation of ANC, exposure to mass media and level of education. Interventions to improve utilisation of the continuum of maternal care should leverage mass media to promote services, especially among the least educated and the residents of Western Uganda.

Predictors of Intrapartum Stillbirths among Women Delivering at Mulago Hospital, Kampala, Uganda.

BACKGROUND: Over the last decade, Uganda has registered a significant improvement in the utilization of maternity care services. Unfortunately, this has not resulted in a significant and commensurate improvement in the maternal and child health (MCH) indicators. More than half of all the stillbirths (54 per 1,000 deliveries) occur in the peripartum period. Understanding the predictors of preventable stillbirths (SB) will inform the formulation of strategies to reduce this preventable loss of newborns in the intrapartum period. The objective of this study was to determine the predictors of intrapartum stillbirth among women delivering at Mulago National Referral and Teaching Hospital in Central Uganda. METHODS: This was an unmatched case-control study conducted at Mulago Hospital from October 29, 2018 to October 30, 2019. A total of 474 women were included in the analysis: 158 as cases with an intrapartum stillbirth and 316 as controls without an intrapartum stillbirth. Bivariable and multivariable logistic regression was done to determine the predictors of intrapartum stillbirth. RESULTS: The predictors of intrapartum stillbirth were history of being referred from lower health units to Mulago hospital (aOR 2.5, 95% CI: 1.5-4.5); maternal age 35 years or more (aOR 2.9, 95% CI: 1.01- 8.4); antepartum hemorrhage (aOR 8.5, 95% CI: 2.4-30.7); malpresentation (aOR 6.29; 95% CI: 2.39-16.1); prolonged/obstructed labor (aOR 6.2; 95% CI: 2.39-16.1); and cesarean delivery (aOR 7.6; 95% CI: 3.2-13.7). CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: Referral to hospital, maternal age 35 years and above, obstetric complication during labor, and cesarean delivery were predictors of intrapartum stillbirth in women delivering at Mulago hospital. Timely referral and improving access to quality intrapartum obstetric care have the potential to reduce the incidence of intrapartum SB in our community.

Covariates of Pica among Pregnant Women Attending Antenatal Care at Kawempe Hospital, Kampala, Uganda: A Cross-Sectional Study.

Pica is the craving and purposive eating of nonfood items. It is common worldwide and presents among vulnerable populations like children and pregnant women. Its etiology and health consequences are not well understood. The aim of this study was to determine the prevalence and covariates of pica among pregnant women attending antenatal clinic at Kawempe hospital in Uganda. We conducted a cross-sectional study from July 2019 to December 2019. Participants in this study were 307 pregnant women who had come to attend antenatal clinic at the hospital. The prevalence of pica was computed. Bivariate and multivariable analysis was done to establish the factors that were independently associated with pica. The prevalence of pica was 57%. The most common type of pica was geophagia (eating clay and sand) followed by pagophagia (eating ice). Of the women who practiced pica, half consumed the nonfood items daily. Factors independently associated with pica were being in the third trimester (adjusted OR [aOR]: 3.60; 95% CI: 1.36-9.48] and having nausea in pregnancy (aOR: 2.11; 95% CI: 1.20-3.70). At Kawempe hospital, pica is common among women who attend the antenatal clinic and is associated with having nausea in pregnancy and being in the third trimester. Health workers need to counsel pregnant women about the dangers of pica so as to reduce helminth infections and micronutrient deficiency associated with it.

Asymptomatic bacteriuria among pregnant women attending antenatal care at Mbale Hospital, Eastern Uganda.

BACKGROUND: Asymptomatic bacteriuria in pregnancy (ASBP) is associated with adverse pregnancy outcomes such as pyelonephritis, preterm or low birth weight delivery if untreated. The aim of this study was to determine the prevalence of asymptomatic bacteriuria, the isolated bacterial agents, and their antibiotic sensitivity patterns in pregnant women attending antenatal care at Mbale Hospital. METHODS: This was a cross sectional study in which 587 pregnant women with no symptoms and signs of urinary tract infection were recruited from January to March 2019. Mid-stream clean catch urine samples were collected from the women using sterile containers. The urine samples were cultured using standard laboratory methods. The bacterial colonies were identified and antibiotic sensitivity was done using disc diffusion method. Chi squared tests and logistic regression were done to identify factors associated with asymptomatic bacteriuria. A p value < 0.05 was considered statistically significant. RESULTS: Out of the 587 pregnant women, 22 (3.75%) tested positive for asymptomatic bacteriuria. Women aged 20-24 years were less likely to have ASBP when compared to women aged less than 20 years (AOR = 0.14, 95%CI 0.02-0.95, P = 0.004). The most common isolates in descending order were E. coli (n = 13, 46.4%) and S.aureus (n = 9, 32.1%). Among the gram negative isolates, the highest sensitivity was to gentamycin (82.4%) and imipenem (82.4%). The gram positive isolates were sensitive to gentamycin (90.9%) followed by imipenem (81.8%). All the isolates were resistant to sulphamethoxazole with trimethoprim (100%). Multidrug resistance was 82.4% among gram negative isolates and 72.4% among the gram positive isolates. CONCLUSION: There was high resistance to the most commonly used antibiotics. There is need to do urine culture and sensitivity from women with ASBP so as to reduce the associated complications.

Adherence to iron supplements among women receiving antenatal care at Mulago National Referral Hospital, Uganda-cross-sectional study.

BACKGROUND: Antenatal iron supplementation is a cost effective way of reducing iron deficiency anaemia among pregnant women in resource limited countries like Uganda. Poor adherence to iron supplements has limited its effectiveness in reducing maternal anaemia as evidenced by the high burden of iron deficiency anemia in Sub-saharan Africa. The aim of this study was to determine the level of and factors associated with adherence to iron supplementation among women attending antenatal clinic at Mulago National Referral Hospital, Kampala, Uganda. METHODS: Three hundred and seventy pregnant women were recruited in a cross sectional survey in Mulago National Referral Hospital antenatal clinic after informed consent between February and April 2014. Levels of adherence to iron supplements were assessed using visual analogue scale and factors associated collected using an interviewer administered questionnaire. RESULTS: About 12% (11.6%) of the mothers attending the antenatal clinic adhered to iron supplements over 30 day period. Mothers who had had four or more antenatal visits prior to the survey [odds ratio (OR) = 1.49, 95% confidence interval (CI) 1.12-1.97], had more than 2 week supply of iron supplements in the previous visit (OR 2.81, 95% CI 1.02-1.09), prior health education (OR 1.56, 95% CI 1.07-2.29) were more likely to adhere to iron supplements. Inadequate drug supplies and fear for side effects were the main reasons why participants missed the iron supplements. CONCLUSIONS: There was low adherence to iron supplements among mothers attending antenatal clinic at Mulago National Referral  Hospital. We recommend a national evaluation of adherence to iron supplements and look at ways of increasing adherence.

Cervicovaginal Bacteriology and Antibiotic Sensitivity Patterns among Women with Premature Rupture of Membranes in Mulago Hospital, Kampala, Uganda: A Cross-Sectional Study.

Background. A 2013 Cochrane review concluded that the choice of antibiotics for prophylaxis in PROM is not clear. In Uganda, a combination of oral erythromycin and amoxicillin is the 1st line for prophylaxis against ascending infection. Our aim was to establish the current cervicovaginal bacteriology and antibiotic sensitivity patterns. Methods. Liquor was collected aseptically from the endocervical canal and pool in the posterior fornix of the vagina using a pipette. Aerobic cultures were performed on blood, chocolate, and MacConkey agar and incubated at 35-37°C for 24-48 hrs. Enrichment media were utilized to culture for GBS and facultative anaerobes. Isolates were identified using colonial morphology, gram staining, and biochemical analysis. Sensitivity testing was performed via Kirby-Bauer disk diffusion and dilution method. Pearson's chi-squared (χ2) test and the paired t-test were applied, at a P value of 0.05. Results. Thirty percent of the cultures were positive and over 90% were aerobic microorganisms. Resistance to erythromycin, ampicillin, cotrimoxazole, and ceftriaxone was 44%, 95%, 96%, and 24%, respectively. Rupture of membranes (>12 hrs), late preterm, and term PROM were associated with more positive cultures. Conclusion. The spectrum of bacteria associated with PROM has not changed, but resistance to erythromycin and ampicillin has increased.

Improving the quality of obstetric care for women with obstructed labour in the national referral hospital in Uganda: lessons learnt from criteria based audit.

BACKGROUND: Obstructed labour remains a major cause of maternal morbidity and mortality whose complications can be reduced with improved quality of obstetric care. The objective was to assess whether criteria-based audit improves quality of obstetric care provided to women with obstructed labour in Mulago hospital, Uganda. METHODS: Using criteria-based audit, management of obstructed labour was analyzed prospectively in two audits. Six standards of care were compared. An initial audit of 180 patients was conducted in September/October 2013. The Audit results were shared with key stakeholders. Gaps in patient management were identified and recommendations for improving obstetric care initiated. Six standards of care (intravenous fluids, intravenous antibiotics, monitoring of maternal vital signs, bladder catheterization, delivery within two hours, and blood grouping and cross matching) were implemented. A re-audit of 180 patients with obstructed labour was conducted four months later to evaluate the impact of these recommendations. The results of the two audits were compared. In-depth interviews and focus group discussions were conducted among healthcare providers to identify factors that could have influenced the audit results. RESULTS: There was improvement in two standards of care (intravenous fluids and intravenous antibiotic administration) 58.9 % vs. 86.1 %; p < 0.001 and 21.7 % vs. 50.5 %; P < 0.001 respectively after the second audit. There was no improvement in vital sign monitoring, delivery within two hours or blood grouping and cross matching. There was a decline in bladder catheterization (94 % vs. 68.9 %; p < 0.001. The overall mean care score in the first and second audits was 55.1 and 48.2 % respectively, p = 0.19. Healthcare factors (negative attitude, low numbers, poor team work, low motivation), facility factors (poor supervision, stock-outs of essential supplies, absence of protocols) and patient factors (high patient load, poor compliance to instructions) contributed to poor quality of care. CONCLUSION: Introduction of criteria based audit in the management of obstructed labour led to measurable improvements in only two out of six standards of care. The extent to which criteria based audit may improve quality of obstetric care depends on having basic effective healthcare systems in place.

The effects of vitamin C supplementation on pre-eclampsia in Mulago Hospital, Kampala, Uganda: a randomized placebo controlled clinical trial.

BACKGROUND: Oxidative stress plays a role in the pathogenesis of pre-eclampsia. Supplementing women with antioxidants during pregnancy may reduce oxidative stress and thereby prevent or delay the onset pre-eclampsia. The objective of this study was to evaluate the effect of supplementing vitamin C in pregnancy on the incidence of pre-eclampsia, at Mulago hospital, Kampala, Uganda. METHODS: This was a (parallel, balanced randomization, 1:1) placebo randomized controlled trial conducted at Mulago hospital, Department of Obstetrics and Gynecology. Participants included in this study were pregnant women aged 15-42 years, who lived 15 km or less from the hospital with gestational ages between 12-22 weeks. The women were randomized to take 1000mg of vitamin C (as ascorbic acid) or a placebo daily until they delivered. The primary outcome was pre-eclamsia. Secondary outcomes were: severe pre-eclampsia, gestational hypertension, preterm delivery, low birth weight and still birth delivery. Participants were 932 pregnant women randomized into one of the two treatment arms in a ratio of 1:1. The participants, the care providers and those assessing the outcomes were blinded to the study allocation. RESULTS: Of the 932 women recruited; 466 were randomized to the vitamin and 466 to the placebo group. Recruitment of participants was from November 2011 to June 2012 and follow up was up to January 2013. Outcome data was available 415 women in the vitamin group and 418 women in the placebo group.There were no differences in vitamin and placebo groups in the incidence of pre-eclampsia (3.1% versus 4.1%; RR 0.77; 95% CI: 0.37-1.56), severe pre-eclampsia (1.2% versus 1.0%; RR 1.25; 95% CI: 0.34-4.65), gestational hypertension(7.7% versus 11.5%; RR 0.67; 95% CI: 0.43-1.03), preterm delivery (11.3% versus 12.2%; RR 0.92; 95% CI: 0.63-1.34), low birth weight (11.1% versus 10.3%; RR 1.07; 95% CI: 0.72-1.59) and still birth delivery (4.6% versus 4.5%; RR 1.01; 95% CI: 0.54-1.87). CONCLUSIONS: Supplementation with vitamin C did not reduce the incidence of pre-eclampsia nor did it reduce the adverse maternal or neonatal outcomes. We do not recommend the use of vitamin C in pregnancy to prevent pre-eclampsia. TRIAL REGISTRATION: This study was registered at the Pan African Clinical Trial Registry, PACTR201210000418271 on 25th October 2012.

Adverse neonatal outcomes in women with pre-eclampsia in Mulago Hospital, Kampala, Uganda: a cross-sectional study.

INTRODUCTION: Pre-eclampsia, which is more prevalent in resource-limited settings, contributes significantly to maternal, fetal and neonatal morbidity and mortality. However, the factors associated with these adverse outcomes are poorly understood in low resource settings. In this paper we examine the risk factors for adverse neonatal outcomes among women with pre-eclampsia at Mulago Hospital in Kampala, Uganda. METHODS: Pre-eclampsia, which is more prevalent in resource-limited settings, contributes significantly to maternal, fetal and neonatal morbidity and mortality. However, the factors associated with these adverse outcomes are poorly understood in low resource settings. In this paper we examine the risk factors for adverse neonatal outcomes among women with pre-eclampsia at Mulago Hospital in Kampala, Uganda. RESULTS: Predictors of adverse neonatal outcomes were: preterm delivery (OR 5.97, 95% CI: 2.97-12.7) and severe pre-eclampsia (OR 5.17, 95% CI: 2.36-11.3). CONCLUSION: Predictors of adverse neonatal outcomes among women with pre-eclampsia were preterm delivery and severe pre-eclampsia. Health workers need to identify women at risk, offer them counseling and, refer them if necessary to a hospital where they can be managed successfully. This may in turn reduce the neonatal morbidity and mortality associated with pre-eclampsia.

Plasma vitamin C assay in women of reproductive age in Kampala, Uganda, using a colorimetric method.

OBJECTIVE: Vitamin C alone or in combination with vitamin E has been proposed to prevent pre-eclampsia. In this study, we assayed the plasma vitamin C in women of reproductive age in Kampala and assessed its association with pre-eclampsia. METHODS: Participants in this study were 215 women with pre-eclampsia, 400 women with normal pregnancy attending antenatal clinic and 200 non-pregnant women attending family planning clinic at Mulago Hospital's Department of Obstetrics and Gynaecology from 1st May 2008 to 1st May 2009. Plasma vitamin C was assayed using the acid phosphotungstate method; differences in the means of plasma vitamin C were determined by ANOVA. RESULTS: Mean plasma vitamin C levels were 1.72 (SD 0.68)×10(3)µg/l in women with pre-eclampsia, 1.89 (SD 0.73)×10(3)µg/l in women with normal pregnancy and 2.64 (SD 0.97)×10(3)µg/l in non-pregnant women. Plasma vitamin C was lower in women with pre-eclampsia than in women with normal pregnancy (P=0.005) and non-pregnant women (P<0.001). CONCLUSION: Health workers need to advise women of reproductive age on foods that are rich in vitamin C, as this may improve the vitamin status and possibly reduce the occurrence of pre-eclampsia.

Risk factors for pre-eclampsia in Mulago Hospital, Kampala, Uganda.

OBJECTIVE: Pre-eclampsia contributes significantly to maternal, foetal and neonatal morbidity and mortality. The risk factors for pre-eclampsia have not been well documented in Uganda. In this paper, we describe the risk factors for pre-eclampsia in women attending antenatal clinics at Mulago Hospital, Kampala. METHODS: This casecontrol study was conducted from 1st May 2008 to 1st May 2009. 207 women with pre-eclampsia were the cases, and 352 women with normal pregnancy were the controls. The women were 15-39 years old, and their gestational ages were 20 weeks or more. They were interviewed about their socio-demographic characteristics, past medical history and, their past and present obstetric performances. RESULTS: The risk factors were low plasma vitamin C (OR 3.19, 95% CI: 1.54-6.61), low education level (OR 1.67, 95% CI: 1.12-2.48), chronic hypertension (OR 2.29, 95% CI 1.12-4.66), family history of hypertension (OR 2.25, 95% CI: 1.53-3.31) and primiparity (OR 2.76, 95% CI: 1.84-4.15) and para≥5 (3.71, 95% CI:1.84-7.45). CONCLUSION: The risk factors identified are similar to what has been found elsewhere. Health workers need to identify women at risk of pre-eclampsia and manage them appropriately so as to prevent the maternal and neonatal morbidity and mortality associated with this condition.

Human immunodeficiency virus and AIDS and other important predictors of maternal mortality in Mulago Hospital Complex Kampala Uganda.

BACKGROUND: Women with severe maternal morbidity are at high risk of dying. Quality and prompt management and sometimes luck have been suggested to reduce on the risk of dying. The objective of the study was to identify the direct and indirect causes of severe maternal morbidity, predictors of progression from severe maternal morbidity to maternal mortality in Mulago hospital, Kampala, Uganda. METHODS: This was a longitudinal follow up study at the Mulago hospital's Department of Obstetrics and Gynaecology. Participants were 499 with severe maternal morbidity admitted in Mulago hospital between 15th November 2001 and 30th November 2002 were identified, recruited and followed up until discharge or death. Potential prognostic factors were HIV status and CD4 cell counts, socio demographic characteristics, medical and gynaecological history, past and present obstetric history and intra- partum and postnatal care. RESULTS: Severe pre eclampsia/eclampsia, obstructed labour and ruptured uterus, severe post partum haemorrhage, severe abruptio and placenta praevia, puerperal sepsis, post abortal sepsis and severe anaemia were the causes for the hospitalization of 499 mothers. The mortality incidence rate was 8% (n = 39), maternal mortality ratio of 7815/100,000 live births and the ratio of severe maternal morbidity to mortality was 12.8:1.The independent predictors of maternal mortality were HIV/AIDS (OR 5.1 95% CI 2-12.8), non attendance of antenatal care (OR 4.0, 95% CI 1.3-9.2), non use of oxytocics (OR 4.0, 95% CI 1.7-9.7), lack of essential drugs (OR 3.6, 95% CI 1.1-11.3) and non availability of blood for transfusion (OR 53.7, 95% CI (15.7-183.9) and delivery of amale baby (OR 4.0, 95% CI 1.6-10.1). CONCLUSION: The predictors of progression from severe maternal morbidity to mortality were: residing far from hospital, low socio economic status, non attendance of antenatal care, poor intrapartum care, and HIV/AIDS.There is need to improve on the referral system, economic empowerment of women and to offer comprehensive emergency obstetric care so as to reduce the maternal morbidity and mortality in our community.

Risk factors for placenta praevia presenting with severe vaginal bleeding in Mulago hospital, Kampala, Uganda.

OBJECTIVE: To determine the risk factors for placenta praevia presenting with severe vaginal bleeding in Mulago hospital, Kampala, Uganda. DESIGN: A case control study. SETTING: Mulago hospital labour suite PARTICIPANTS: Between 15th November 2001 and 30th November 2002 we identified and recruited thirty six parturients with placenta previa who developed severe bleeding and 180 women with normal delivery. The risk factors were studied. VARIABLES OF INTEREST: Socio demographic characteristics, social and family history, gynaecological operations, blood transfusion, medical conditions, past and present obstetric performance and HIV status. RESULTS: Significant predictors for severe bleeding in parturients with placenta praevia were: previous history of evacuation of the uterus or dilation and curettage (O.R. 3.6, CI: 1.1-12.5), delivery by caesarean section in previous pregnancy (O.R. 19.9, CI: 6.4-61.7), residing more than ten kilometres from Mulago hospital (O.R. 2.4, CI: 1.0-5.7) and recurrent vaginal bleeding during the current pregnancy (O.R. 7.3, CI 2.4-63.7). CONCLUSION: Severe bleeding in placenta praevia is associated with high maternal morbidity and mortality. The determinants of severe bleeding in placenta praevia can be used in the antenatal period to identify mothers at risk. These, with prompt interventions to deliver the women can be used to reduce the maternal morbidity associated with this condition.

Clinical presentation and management of alleged sexually assaulted females at Mulago hospital, Kampala, Uganda.

OBJECTIVE: To determine the presentation and treatment offered to sexually assaulted females attending emergency gynaecological ward in Mulago Hospital, Kampala, Uganda. SETTING: Mulago hospital gynaecological emergency ward. STUDY DESIGN: Prospective descriptive study. PARTICIPANTS: Fifty eight sexually assaulted females were recruited from 1 st March 2000 to 31 st December 2000. They were interviewed, examined, given appropriate treatment and followed up for three months. OUTCOME VARIABLES: Socio demographic characteristics, genital and bodily injuries, relationship to the assailant, and prevalence of sexually transmitted infections. RESULTS: The mean age was 9.5 with a range of 1-35 years. Seventy two percent of the victims were children below 12 years. Fifty percent of the assault occurred at the assailant's home. The majority (79.3%) of the victims knew the assailant and cases of gang rape were only 6.9%. The injuries sustained were extra genital (19.0%), genital (75.4%). The emotional or psychological disturbance was present in 22.4% of the patients. The sexually transmitted infections found included trichomonas vaginalis (1.7%) and syphilis (3.7%). All cases received counseling and prophylactic treatment for sexually transmitted infections. Those in reproductive age group were offered emergency contraception. None of the victims got post exposure HIV therapy because it was not available in the hospital. CONCLUSION: Sexual assault is common in Uganda and is one of the most dehumanizing human crimes against women. It is associated with adverse medical and social problems. There is urgent need to sensitize the community about reporting early for medical treatment after sexual assault.