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.

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 Chlamydia trachomatis in women attending a family planning clinic in Papua New Guinea.

OBJECTIVE: To determine the prevalence of Chlamydia trachomatis infection in women attending a family planning clinic in Papua New Guinea, in the period between April and June 1991. SETTING: The outpatient department of Obstetrics and Gynaecology of Port Moresby General Hospital, Port Moresby, Papua New Guinea, the departments of Dermato-Venereology and Clinical Microbiology of the Erasmus University, Rotterdam, The Netherlands and the National Institute of Public Health and Environmental Protection, Bilthoven, The Netherlands. PATIENTS: A total of 254 consecutive women who attended the family planning clinic at Port Moresby General Hospital, Papua New Guinea were enrolled into this study. METHODS: Cervical infections with C trachomatis were diagnosed using the direct immunofluorescent assay (DFA) and the polymerase chain reaction (PCR). Serum IgM and IgG antibodies directed against C trachomatis were detected using the enzyme-linked fluorescent assay (ELFA). RESULTS: The prevalence of C trachomatis was 14.6% using the PCR, 9.1% using the DFA and 17.3% when the results of the PCR and the DFA were combined. An elevated IgM titre was observed in 14.2% of the women, whereas 44.1% had an elevated IgG titre. The titres of IgM or IgG were significantly higher in women who were positive using the PCR or the DFA than in those who were negative in both the PCR and the DFA (p = 0.032 and p = 0.0046, respectively). CONCLUSION: Cervical infection by C trachomatis can be considered a major health problem in at least the studied population in Papua New Guinea. The prevalence of C trachomatis infection is at least comparable with that in groups with a high prevalence in industrialized countries. Effective screening and treatment programmes are imperative to combat this problem.

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.

Primary postpartum haemorrhage: causes, aetiological risk factors, prevention and management.

PIP: The causes, risk factors, prevention, and clinical management of primary postpartum hemorrhage--a major cause of maternal mortality--are outlined in this report for clinicians. The major causes of primary postpartum hemorrhage include uterine atony, retained placenta, lower genital tract lacerations and hematomas, uterine rupture, consumptive coagulopathy, and acute inversion of the uterus. Detailed, step-by-step clinical management guidelines are presented for hemorrhage associated with each of these causes. Immediate and late complications of primary postpartum hemorrhage include hypovolemic shock, cerebral anoxia, renal failure, anemia, puerperal sepsis, and Sheehan's syndrome. The antepartum hemoglobin status and the rate of blood loss influence hemorrhage outcome.^ieng

A survey of Papua New Guinean parturients at the Port Moresby General Hospital: family planning.

A survey of 673 consecutive Papua New Guinean parturients at the Port Moresby General Hospital, in May and June 1990, showed that 28% had ever used a family planning (FP) method, chiefly a hormonal method (93% of ever-users). Only seventeen of 239 (7.1%) nulliparae had ever used an FP method, compared with 170 of 434 (39.2%) parous subjects. Education of mother and of husband were independently and significantly associated with FP ever-use. Seventeen (4.9%) of 347 women who had a surviving child, had not breast-fed the child. The interval between the birth of the surviving child and the start of the index pregnancy was significantly associated with the duration of breast-feeding; the longer the duration of breast-feeding, the longer the inter birth interval.

PIP: A 1990 survey of 673 postpartum women at Port Moresby General Hospital in Papua New Guinea found that 27.8% had used a family planning method as a means of delaying or avoiding pregnancy. 92.7% of ever use was with the oral pill or the injectable Depo-Provera. Educational level of the mother or the father was significantly associated with contraceptive usage among multiparous women. Having some education by either spouse was significantly related in the absence of education of the other spouse. The mean years of schooling among family planning users was 14.7 years and significantly different from the 12.7 years for never-users. Parity was also significantly related to ever use of family planning. 31% of 667 respondents reported that the index pregnancy had not been planned. The planned pregnancy was unrelated to maternal or paternal educational status or parity. 122 or 16.5% of those with a planned index birth had used a family planning method prior to conception. 11.3% in the unplanned index birth group had used a contraceptive method prior to the pregnancy; the differences were significant. Longer duration of breast feeding was related to longer birth interval regardless of whether or not contraception was used. Ever use of family planning was significantly higher among those of a mid-high social class than among those in the low social class. 49.1% of the 654 respondents reported no intention to use family planning. 41% planned to use the oral pill or injectables. 0.6% planned to use an IUD, and 8.9% reported plans for a tubal ligation. Of the 58 planning female sterilization, 79.3% (46) had the operation before returning home. The findings reflected the lack of family planning promotion within the larger community among non-pregnant women.

A survey of Papua New Guinean parturients at the Port Moresby General Hospital: sociodemographic and reproductive characteristics.

A survey of 673 consecutive Papua New Guinea parturients carried out at the Port Moresby General Hospital between May and June 1990 showed that socioeconomic and educational factors played a part in predicting perinatal death. Mothers who have previously experienced a perinatal death are more likely to experience a second one.

PIP: During May-June, 1990, physicians surveyed all postpartum women before they were discharged from Port Moresby General Hospitals of Papua New Guinea to determine whether socioeconomic and educational factors contributed to perinatal death as well as to low birth weight. Most of the 673 women were of southern origin (70%), currently married (97.2%), 20-35 years old (79.5%), and had 1-4 children prior to the index birth (57.4%). 4.6% had experienced at least 1 perinatal death before the index infant. The perinatal death rate among the index births (676 births) was 29.6/1000 births (stillbirth rate = 22.2/1000 births and neonatal mortality rate = 7.4/1000). The main cause of perinatal death were antepartum hemorrhage, prematurity and respiratory distress syndrome, syphilis, and placental insufficiency associated with intrauterine growth retardation. The stepwise logistic regression analysis indicated that village/urban slum residence, prenatal care, and previous perinatal death were significantly associated with perinatal death. The odds ratios of village/urban slum residence (p = .001), lack of prenatal care in index pregnancy (p = .002) were 5.13, 4.18, and 5,38, respectively. Predictors of low birth weight were village/urban slum residence (OR = 2.67; p .001), nulliparity before index birth (OR = 2.29; p .001), and previous perinatal death (OR = 2.87; p .05). These findings showed that mothers who have previously suffered from a perinatal death are more likely to again experience a perinatal death.

The prevalence of toxoplasma antibodies in pregnant patients attending the Port Moresby General Hospital antenatal clinic: a seroepidemiological survey.

In a survey of 197 consecutive pregnant patients who were attending the Port Moresby General Hospital antenatal clinic for the first time in the index pregnancy, the prevalence of IgG antibodies to Toxoplasma gondii was 18%. Only one patient had IgM antibodies. Of the sociodemographic characteristics examined, only highlands origin of the patient had a significant association with the presence of IgG antibodies.

Normal birthweight at Port Moresby General Hospital: a retrospective survey of normal term births to determine birthweight distribution.

A retrospective survey was carried out of term babies born to Papua New Guinean parents at the Port Moresby General Hospital. Only babies of known gestational age from uncomplicated pregnancies who were delivered after 37 and before 42 completed weeks were included in the study. The purpose of the study was to determine the birthweight distribution at term of uncomplicated pregnancies for Papua New Guineans at the Port Moresby General Hospital. The sources of the data were the patients' case records and the labour ward register. The Epi Info V5 (CDC and WHO) statistical software package was used for the analysis. 404 subjects were studied; 116 of these were nulliparae before the index delivery. For the whole study population some of the findings were as follows: mean birthweight 3251g, standard deviation 403.5, mode 3100g, median 3250g, 10th percentile 2713g, 90th percentile 3750g. Birthweight at 41-42 weeks was significantly greater than at 37-38 completed weeks. The height and parity of the mother and sex of the baby also had significant effects on birthweight but the latest birth interval had no significant influence. Babies of highland mothers were significantly heavier than babies of Papuan mothers.

A comparison of unbooked mothers delivering at Port Moresby General Hospital with mothers seen antenatally: socioeconomic and reproductive characteristics.

It is well known that antenatal care improves perinatal and maternal outcomes. This is especially true for deprived communities and for the developing world, where women commonly have risk factors. At the Port Moresby General Hospital mothers who did not attend an antenatal clinic in the index pregnancy (unbooked mothers) form about 6% of all mothers delivered. These unbooked mothers have a perinatal death rate which is four times that of those who attended antenatal clinics before their delivery. A case-control survey was conducted of 136 unbooked mothers delivered at the Port Moresby General Hospital and 136 parity-matched control mothers who had been seen antenatally at least three times during their pregnancy. The purpose of the study was to find out if the cases and controls differed in their socioeconomic characteristics and in some selected aspects of their reproductive history. There was no significant difference between the groups in the following: marital status, and distance between present residence and nearest antenatal clinic. The groups were very significantly different in the following characteristics: age less than 20 years, social class, husband's education, and previous antenatal attendance in the penultimate pregnancy. The difference in patient's education was only just significant.

Endocervical Chlamydia trachomatis infection in pregnancy: direct test and clinico-sociodemographic survey of pregnant patients at the Port Moresby General Hospital antenatal clinic to determine prevalence and risk markers.

The prevalence of endocervical C. trachomatis infection in 181 consecutive antenatal clinic patients at the first attendance and who had not received antibiotic therapy in the previous 4 weeks, was 17.7%. The direct fluorescent antibody test was used for diagnosis. There was no significant clinical or sociodemographic factor which distinguished patients who tested positive from those who tested negative.