Jagidesa Moodley

The confidential enquiry into maternal deaths in South Africa : a case study

The Confidential Enquiry into Maternal Deaths (CEMD) in South Africa has been operational for 15 years. This case study describes the process of notification and independent assessment of maternal deaths, predominantly in facilities. In the earlier years of the Enquiry, institutional maternal mortality ratio increased and was 176.2 per 100 000 live births in the 2008–10 triennium; thereafter it decreased to 146.7 in the 2011/12 period. The slow progress was due to the significant contribution of HIV/AIDs to maternal mortality and challenges in implementing the recommendations that were devised from the findings of the Enquiry. Nevertheless, the CEMD process has been maintained and strengthened so it is currently able to perform routine maternal death surveillance at both national and district levels, identify deficiencies within the health system, generate reports and also provide early warning about alarming trends such as the increasing numbers of deaths due to caesarean‐section‐associated haemorrhage.

Sildenafil citrate improves fetal outcomes in pregnant, l-NAME treated, Sprague–Dawley rats

OBJECTIVES This study aimed to investigate the effects of sildenafil citrate on various fetal and physiological parameters, including fetal mortality, number of pups, placental weights and micro-albuminuria in pregnant, L-NAME treated Sprague-Dawley rats. STUDY DESIGN Twenty-four pregnant female Sprague-Dawley rats were divided into 3 groups (n=8). In the L-NAME treated group (PRE), l-NAME (0.3 g/l, drinking water) was used to induce pre-eclampsia-like symptoms on day 1 of the experiment. The experimental group (SCT) also received L-NAME (0.3 g/l, drinking water) on day 1 of the experiment. However, sildenafil citrate (10 mg/kg, s.c., daily) was administered as the test compound from day 7 until day 19. The experimental control (CON) did not receive either L-NAME or sildenafil citrate. L-NAME administration was discontinued in both the PRE and the SCT groups on day 19 of the experiment and the animals were given access to normal drinking water ad libitum. All the animals were sacrificed on day 20, at which time a laparotomy was performed and the various fetal parameters measured. On day 0 and day 20, blood pressure measurements were recorded non-invasively and protein estimations in 24h urine samples were conducted. RESULTS Sildenafil citrate decreased fetal mortality and protein excretion and further demonstrated a trend toward increasing birth and placental weights in pregnant, L-NAME treated, Sprague-Dawley rats. In addition, sildenafil citrate administration ameliorated the amplification of the L-NAME induced hypertension in the SCT group. CONCLUSION We speculate that sildenafil citrate by potentiating the effects of nitric oxide in vivo improves uterine artery blood flow resulting in improved fetal outcomes in pregnant, L-NAME treated, Sprague-Dawley rats.

Pre-eclampsia : its pathogenesis and pathophysiolgy : review articles

Abstract Pre-eclampsia is a pregnancy-specific disorder that has a worldwide prevalence of 5–8%. It is one of the main causes of maternal and perinatal morbidity and mortality globally and accounts for 50 000–60 00 deaths annually, with a predominance in the low- and middle-income countries. It is a multisystemic disorder however its aetiology, pathogenesis and pathophysiology are poorly understood. Recently it has been postulated that it is a two-stage disease with an imbalance between angiogenic and anti-antigenic factors. This review covers the latest thoughts on the pathogenesis and pathology of pre-eclampsia. The central hypothesis is that pre-eclampsia results from defective spiral artery remodelling, leading to cellular ischaemia in the placenta, which in turn results in an imbalance between anti-angiogenic and pro-angiogenic factors. This imbalance in favour of anti-angiogenic factors leads to widespread endothelial dysfunction, affecting all the maternal organ systems. In addition, there is foetal growth restriction (FGR). The exact aetiology remains elusive.

Maternal deaths due to hypertensive disorders in pregnancy

Hypertensive disorders of pregnancy (HDP) are one of the most common direct causes of maternal mortality worldwide. Cerebral haemorrhage is the main final cause of hypertensive deaths and probably implies that doctors are reluctant to treat sustained high blood pressure effectively during pregnancy. Maternal deaths from HDP can probably be reduced markedly by: (1) promoting antenatal care and instituting a recall system for defaulters; (2) instituting regional centres and regional obstetricians to provide advice on, or care for, women with severe pre-eclampsia; (3) educating health professionals through continuing professional education and the use of clinical guidelines of management; and (4) informing the general public on complications associated with the pre-eclampsia/eclampsia syndrome.

The Accuracy of Urine Dipsticks as a Screening Test for Proteinuria in Hypertensive Disorders of Pregnancy

Background. Proteinuria is used as a criterion in the classification system for hypertensive disorders of pregnancy including preeclampsia. The aim of the study was to evaluate the accuracy of dipstick urinalysis in a single voided urine sample and in an aliquot of a 24-hour urine collection in the assessment of proteinuria in hypertensive pregnant women, using the 24-hour urine protein excretion as the gold standard. Methods. One hundred ninety-eight women who presented with hypertension in pregnancy were recruited at the antenatal clinic at King Edward VIII Hospital in Durban, South Africa, a tertiary referral center. Exclusion criteria included women with eclampsia, urinary tract infection, and chronic renal disease. Routine dipstick urinalysis (Bayer) was performed by midwives for proteinuria, and a 24-hour urine specimen was collected for quantitative protein assessment. A laboratory technician performed urine dipstick test for protein on a mixed aliquot of the 24-hour urine specimen. This result, together with that of the screening dipstick urinalysis, was compared to the 24-hour urine protein excretion. Results. The results of the 198 patients were analyzed, of the total, 72 had preeclampsia. Using a value of ≥ 0.3 g protein excretion per 24 hours (1 + to 4 + on urine dipsticks) as positive, sensitivity, specificity, and predictive values for dipstick urinalysis were calculated. The positive predictive value for dipstick urinalysis ranged from 64.9% (single voided urine sample) to 94.2% (24-hour urine aliquot). The negative predictive value ranged from 75.2% (single voided urine sample) to 84.2% (24-hour urine aliquot). Conclusion. Dipstick urinalysis is not very accurate: therefore, all women presenting with hypertension during pregnancy should have a 24-hour urine protein measurement.

5,10 methylenetetrahydrofolate reductase polymorphism in black South African women with pre‐eclampsia

The polymorphic C677T mutation in the gene encoding 5,10 methylenetetrahydrofolate reductase has been shown to be a risk factor for pre‐eclampsia in Japanese and European women when inherited as a homozygous trait. We attempted to verify these findings in a black African population with a high incidence of pre‐eclampsia. No difference in frequency of the T‐allele was observed in 105 women with pre‐eclampsia, compared with 110 healthy pregnant normotensive women. Only one woman with pre‐eclampsia was TT homozygous, suggesting that methylenetetrahydrofolate reductase polymorphism is not an important factor in the pathogenesis of pre‐eclampsia in black South African women.

Sildenafil citrate decreases sFlt-1 and sEng in pregnant l-NAME treated Sprague–Dawley rats

OBJECTIVES We have previously shown that sildenafil citrate improves various fetal outcomes in pregnant, L-NAME treated, Sprague-Dawley rats. We therefore aimed to identify which component/s of this diverse pathophysiologic cascade is/are improved by this drug. STUDY DESIGN This study is a sub-analysis of plasma samples obtained in a previous study in which 24 pregnant Sprague-Dawley dams were divided into three groups (n=8) i.e. the control group (CON), the experimental control group (PRE) where the pre-eclampsia-like symptoms were induced using l-NAME, and the experimental group (SCT) where the pre-eclampsia-like symptoms were once again induced using L-NAME but these animals were treated with sildenafil citrate. On gestation day 20 blood samples were collected in heparin-coated tubes and plasma samples were then analysed for specific variables using commercially available kits for rats. RESULTS There was a significant increase in the plasma levels of soluble fms-like tyrosine kinase1 (sFlt-1) in the PRE group (1228.80±116.29 pg/ml) when compared to the CON (774.91±26.81 pg/ml) and SCT (698.98±20.78 pg/ml) groups, respectively (p<0.001). The plasma levels of soluble endoglin (sEng) were significantly decreased in the SCT group (149.47±3.72 ng/ml) when compared to the CON (178.52±5.33 ng/ml) and PRE (183.44±8.294 ng/ml) groups, respectively (p<0.01). Plasma nitric oxide and l-arginine levels showed a decreasing trend in the PRE groups when compared to the control (CON) and treated (SCT) groups, respectively. CONCLUSION Sildenafil citrate reduces the plasma levels of anti-angiogenic factors, sFlt-1 and sEng, in pre-eclamptic (L-NAME induced) Sprague-Dawley rats and may therefore be responsible for the reduction in blood pressure and proteinuria as well as the improved fetal outcomes noted in an earlier study.

Strengthening HIV services for pregnant women: an opportunity to reduce maternal mortality rates in Southern Africa/sub-Saharan Africa

Please cite this paper as: Moodley J, Pattinson R, Baxter C, Sibeko S, Abdool Karim Q. Strengthening HIV services for pregnant women: an opportunity to reduce maternal mortality rates in Southern Africa/sub‐Saharan Africa. BJOG 2011;118:219–225.

The effect of HIV infection on maternal health and mortality

The effect of HIV infection on maternal mortality is best documented in South Africa, where HIV prevalence rates in pregnancy are among the highest in the world. Since 1998, detailed data on maternal deaths in South Africa have been available in the form of Confidential Enquiries reports. The latest report (Saving Mothers Report, 2005–2007) suggests that the maternal mortality ratio in HIV‐infected women was about 10 times higher than in uninfected women. This was in a context where only a small minority of HIV‐positive pregnant women were receiving HAART. The most common causes of maternal death among HIV‐positive women were nonpregnancy‐related infections, including AIDS, pneumonia, tuberculosis, and meningitis. HIV‐infected pregnant women were also at greater risk of dying from pregnancy‐related sepsis and complications of abortion than their uninfected counterparts. Reduction of HIV‐related maternal deaths must be seen as a worldwide priority in maternal health care.

Medical vs. surgical evacuation of first-trimester spontaneous abortion

Objective: To determine whether management of incomplete first‐trimester abortion with vaginal misoprostol in an under‐resourced setting is a viable treatment option. Methods: A total of 94 women were randomized to 600 μg of misoprostol intravaginally or to surgical curettage. The women receiving misoprostol were administered a second dose if the abortion was incomplete; and if still not complete after a week, evacuation of retained products of conception was performed. All women had a follow‐up visit 2 weeks following complete abortion. Results: The overall success rate of medical management was 91.5%, with 15 of 47 successful cases after 1 dose of misoprostol; 8.5% of the 47 women required evacuation of retained products of conception after 1 week because of treatment failure. The success rate in the surgical arm was 100%. Patients in the medical arm had a longer duration of bleeding and a greater need for analgesia. There were no differences in hemoglobin levels, white blood cell count, adverse effects, pain score, and satisfaction with treatment at the follow‐up visit. However, more women who received the medical treatment would recommend it or choose it in the future. Conclusion: Medical management using 600 μg of misoprostol in 2 doses is effective to treat incomplete first‐trimester abortions in an under‐resourced setting when there is no evidence of uterine sepsis.