Lut Geerts

Routine obstetric ultrasound examinations in South Africa: cost and effect on perinatal outcome–a prospective randomised controlled trial

Objective To compare routine midtrimester with selective obstetric ultrasonography concerning the Health Service cost and the effect on perinatal outcome.

A case of hydatid cyst associated with postpartum maternal death

A young, apparently healthy woman from a rural area in South Africa presented in the third trimester of pregnancy with a symptomatic abdominal mass between the uterine fundus and liver. The etiology was established to be an echinococcus cyst of the liver and medical treatment was initiated. The fetal outcome was good but the mother died 3 days postpartum due to an unusual but devastating complication of the hydatid cyst. Copyright

Maternal childhood trauma, postpartum depression, and infant outcomes: Avoidant affective processing as a potential mechanism

BACKGROUND Women who have experienced childhood trauma may be at risk for postpartum depression, increasing the likelihood of negative outcomes among their children. Predictive pathways from maternal childhood trauma to child outcomes, as mediated by postpartum depression, require investigation. METHODS A longitudinal sample of South African women (N=150) was followed through pregnancy and postpartum. Measures included maternal trauma history reported during pregnancy; postpartum depression through six months; and maternal-infant bonding, infant development, and infant physical growth at one year. Structural equation models tested postpartum depression as a mediator between maternal experiences of childhood trauma and childrens outcomes. A subset of women (N=33) also participated in a lab-based emotional Stroop paradigm, and their responses to fearful stimuli at six weeks were explored as a potential mechanism linking maternal childhood trauma, postpartum depression, and child outcomes. RESULTS Women with childhood trauma experienced greater depressive symptoms through six months postpartum, which then predicted negative child outcomes at one year. Mediating effects of postpartum depression were significant, and persisted for maternal-infant bonding and infant growth after controlling for covariates and antenatal distress. Maternal avoidance of fearful stimuli emerged as a potential affective mechanism. LIMITATIONS Limitations included modest sample size, self-report measures, and unmeasured potential confounders. CONCLUSIONS Findings suggest a mediating role of postpartum depression in the intergenerational transmission of negative outcomes. Perinatal interventions that address maternal trauma histories and depression, as well as underlying affective mechanisms, may help interrupt cycles of disadvantage, particularly in high-trauma settings such as South Africa.

Effectiveness of prenatal screening for Down syndrome on the basis of maternal age in Cape Town

OBJECTIVE The prenatal screening programme for Down syndrome (DS) in the South African public health sector remains primarily based on advanced maternal age (AMA). We assessed the changes over time and effectiveness of this screening programme within a Cape Town health district. METHODS Retrospective analysis of the Groote Schuur Hospital Cytogenetic Laboratory and Pregnancy Counselling Clinic databases and audit of maternal delivery records at a primary health care facility. RESULTS The number of amniocenteses performed for AMA in consecutive 5-year periods reduced progressively from 786 in 1981 - 1985 to 360 in 2001 - 2005. Comparing prenatal with neonatal diagnoses of DS, the absolute number and the proportion diagnosed prenatally have remained relatively constant over time. The Pregnancy Counselling Database showed that, of 507 women receiving genetic counselling for AMA in 2008 - 2009, 158 (3.1.1%) accepted amniocentesis--uptake has reduced considerably since the early 1990s. The audit of women delivering at a primary care facility found that only 10 (16.4%) of 61 AMA women reached genetic counselling in tertiary care: reasons included late initiation of antenatal care and low referral rates from primary care. CONCLUSION Prenatal screening and diagnosis for DS based on AMA is working ineffectively in the Cape Town health district assessed, and this appears to be representative of a broader trend in South Africa. Inclusion of fetal ultrasound in the process of prenatal screening for DS should be explored as a way forward.

Psychosocial predictors of fetoplacental blood flow during pregnancy

BACKGROUND Although a number of studies have found significant associations between maternal psychological distress, anxiety and changes in fetoplacental blood flow, findings remain inconsistent. A recent pilot study by our group highlighted some of these inconsistencies. In the current study, we expanded this pilot analysis to include psychological distress, anxiety and a range of antenatal variables, with the aim of identifying predictors of fetoplacental blood flow. METHODS Healthy pregnant women (n=148) underwent Doppler flow studies on uterine, umbilical and fetal arteries; as well as assessments of distress, anxiety and other antenatal variables (e.g. perceived social support, resilience, nicotine and alcohol use) in each trimester. RESULTS Stepwise regression analyses found that state anxiety was associated with lower mid-cerebral artery pulsatility index at trimester 3. LIMITATIONS Subjects were recruited from selected midwife obstetric units in the same health district, so the generalizability of our results may be limited. While most subjects received Doppler assessment at trimesters 2 and 3, only approximately half of our sample was assessed at trimester 1. CONCLUSION The finding that anxiety is associated with increased blood flow to the fetal brain during trimester 3 of pregnancy, coincide with previous work. The findings emphasize a growing appreciation of the potential importance of psychological well-being during pregnancy for infant development. However, as associations were small and variable, further research using multivariate models to determine the precise mechanisms underlying these associations would be warranted.

Prenatal diagnosis of chromosomal abnormalities in a resource-poor setting.

To compare the efficacy and efficiency of systematic, ultrasound‐based risk adjustment using a published algorithm with that of a maternal age cutoff of 37 years for the prenatal detection of chromosomal abnormalities (especially autosomal trisomies).

Congenital rubella with agenesis of the inferior cerebellar vermis and total anomalous pulmonary venous drainage.

Congenital rubella infection has been associated with a number of abnormalities including cardiac, central nervous system and placental complications. We present a case with multiple fetal abnormalities detected on prenatal ultrasound, and confirmed postnatally, that included a single umbilical artery, severe tricuspid regurgitation, micrognathia and agenesis of the inferior cerebellar vermis. Postnatal echocardiography additionally revealed unobstructed total anomalous pulmonary venous drainage (TAPVD) into the coronary sinus. Placental examination showed signs of placentitis, and polymerase chain reaction on neonatal serum was positive for rubella. Following a multidisciplinary team review, it was decided to provide only supportive care, and the infant died at 6 months of age owing to a respiratory tract infection. To our knowledge, TAPVD and agenesis of the inferior cerebellar vermis have not been reported previously in association with congenital rubella infection. This case illustrates how congenital infection may present in atypical ways and stresses the importance of considering congenital infection in the differential diagnosis of fetal anomalies when multiple features are present. Copyright

Which is the most accurate formula to estimate fetal weight in women with severe preterm preeclampsia

Objective. To identify the most accurate formula to estimate fetal weight (EFW) from ultrasound parameters in severe preterm preeclampsia. Methods. In a prospective study, serial ultrasound assessments were performed in 123 women with severe preterm preeclampsia. The EFW, calculated for 111 live born, normal, singleton fetuses within 7 days of delivery using 38 published formulae, was compared to the actual birth weight (ABW). Accuracy was assessed by correlations, mean (absolute and signed) (%) errors, % correct predictions within 5–20% of ABW and limits of agreement. Results. Accuracy was highly variable. Most formulae systematically overestimated ABW. Five Hadlock formulae utilizing three or four variables and Woo 3 formula had the highest accuracy and did not differ significantly (mean absolute % errors 6.8–7.2%, SDs 5.3–5.8%, > 75% of estimations within 10% of ABW and 95% limits of agreement between -18/20% and +14/15%). They were not negatively affected by clinical variables but had some inconsistency in bias over the ABW range. All other formulae, including those targeted for small, preterm or growth restricted fetuses, were inferior and/or affected by multiple clinical variables. Conclusion. In this GA window, Hadlock formulae using three or four variables or Woo 3 formula can be recommended.

A centile chart for fetal weight for gestational ages 24 - 27 weeks

The centile chart currently in use for Western Cape birth weight for gestational age covers a gestational age range from 28 to 42 weeks. Advances in maternal fetal and neonatal medicine allow interventions prior to 28 weeks; a growing need therefore exists to extend the chart down to at least 24 weeks. Birth or fetal weight centile charts used in the USA Canada and the UK provide centiles commencing from either 22 or 24 weeks. These charts may not however be appropriate for the population of the Western Cape. The accuracy of fetal or birth weight for gestational age centile charts can be improved by including only women who had their gestational age confirmed by early ultrasound prior to gestational age of 24 weeks. In addition the birth weight of preterm delivered neonates should not be used to establish a norm as these infants were delivered following maternal and/or obstetric complications. The ultrasonic estimated fetal weight (EFW) is the method of choice to establish a reference range for weight for gestational age in early gestation. The EFW should be used in preference to any single ultrasound measurement as it relies on multiple measurements. The aim of this study was to construct a centile chart from 24 to 27 weeks for fetal weight for gestational age taking the above criteria into account. (excerpt)

Placental insufficiency among high-risk pregnancies with a normal umbilical artery resistance index after 32 weeks

To determine the incidence of abnormal multi‐vessel Doppler values among advanced pregnancies at risk of suboptimal placentation but with a normal umbilical artery resistance index (RI), and to assess whether clinical and ultrasonography findings can identify them.