Maternal mortality due to cardiac disease in Sri Lanka

Objective

To investigate Sri Lankan maternal deaths due to heart disease and to consider low-cost interventions to reduce these deaths.

Methods

A qualitative study based on retrospective audit of all maternal deaths and late maternal deaths in Sri Lanka caused by cardiac disease in 2004.

Results

A total of 145 maternal deaths were recorded in 2004, for a maternal mortality rate of 38 per 100 000. There were 42 indirect deaths, 25 of which were due to cardiac disease; 23 deaths had a specific cardiac cause listed. Standard care was identified in prepregnancy counseling, contraception, and prenatal community and specialist care.

Conclusion

Cardiac disease is a major cause of maternal mortality in Sri Lanka, second only to postpartum hemorrhage. Rheumatic mitral valve disease is responsible for more than a third of maternal deaths from cardiac disease. Substandard care was identified in all cases; strategies to improve care could allow a reduction in maternal cardiac deaths.     

The influence of maternal body composition on birth weight

Objective

To identify the maternal body composition parameters that independently influence birth weight.

Study design

A longitudinal prospective observational study in a large university teaching hospital. One hundred and eighty-four non-diabetic caucasian women with a singleton pregnancy were studied. In early pregnancy maternal weight and height were measured digitally in a standardised way and the body mass index (BMI) was calculated. At 28 and 37 weeks’ gestation maternal body composition was assessed using segmental multifrequency bioelectrical impedance analysis. At delivery the baby was weighed and the clinical details were recorded.

Results

Of the women studied, 29.2% were overweight and 34.8% were obese. Birth weight did not correlate with maternal weight or BMI in early pregnancy. Birth weight correlated with gestational weight gain (GWG) before the third trimester (r = 0.163, p = 0.027), but not with GWG in the third trimester. Birth weight correlated with maternal fat-free mass, and not fat mass at 28 and 37 weeks gestation. Birth weight did not correlate with increases in maternal fat and fat-free masses between 28 and 37 weeks.

Conclusions

Contrary to previous reports, we found that early pregnancy maternal BMI in a non-diabetic population does not influence birth weight. Interestingly, it was the GWG before the third trimester and not the GWG in the third trimester that influenced birth weight. Our findings have implications for the design of future intervention studies aimed at optimising gestational weight gain and birth weight.

Condensation

Maternal fat-free mass and gestational weight gain both influence birth weight.     

Influencia de la visita puerperal temprana en la detección y evolución de la depresión posparto

Objectives

The aim of this study was to determine the influence of early postpartum home visits in reducing the incidence of puerperal depression in our environment.

Material and methods

A total of 430 patients with uncomplicated pregnancy and delivery were randomized to two homogeneous groups (one group receiving an early postpartum home visit and a control group). The hospital anxiety and depression scale was used to assess puerperal depression at 7 and 30 days.

Results

At 7 days, 10.2% of the patients had a positive score for puerperal depression. At 30 days, the incidence of puerperal depression was lower in the group receiving an early home visit (0.9%) than in the control group (3.7%).

Conclusion

The incidence of postpartum depression in our setting was similar to the expected incidence. Early postpartum home visits seem to be useful in detecting this disorder and in reducing symptoms.     

First trimester ultrasound estimation of gestational age in pregnancies conceived after in vitro fertilization

Objective

To evaluate BPD as an alternative to CRL for the estimation of gestation age in late first trimester pregnancies (between 9th and 13th gestational weeks), and to construct a first trimester reference chart of fetal BPD growth.

Study design

A prospective study that compared the gestational age estimated by BPD and CRL with the IVF gestational age in 167 first trimester pregnancies (127 singletons, 40 twins).

Results

Both BPD and CRL correlated well with the IVF gestational age (GA) from 9th to 13th gestation weeks. When comparing the difference of the GA (in days) estimated from the two respective ultrasound parameters versus the GA based on IVF (oocyte retrieval day +14 days), BPD estimations had a significantly lower mean difference than CRL (0.013 vs. 0.746; p < 0.01), as well as a lower standard deviation (2.414 vs. 3.008; p < 0.05). In addition, the 95% limits of agreement between the BPD estimated GA and IVF GA were also smaller than CRL estimated GA versus IVF GA (−4.719 to 4.745 vs. −5.149 to 6.641).

Conclusion

Biparietal diameter shares similar accuracy with crown rump length in late first trimester ultrasound estimation, with additional advantages of lower random measurement errors.     

Bone turnover and maternal 25(OH) vitamin D3 levels during pregnancy and the postpartum period: should routine vitamin D supplementation be increased in pregnant women?

Objective

To investigate the relationship between 25(OH) vitamin D3 levels and maternal bone turnover during pregnancy and lactation.

Study design

Thirty pregnant women and 30 healthy non-pregnant controls were included the study. The pregnant women were examined in the 12th, 25th and 32nd gestational weeks and 6 weeks after delivery. The controls were examined once. Serum concentrations of 25(OH) vitamin D3, parathyroid hormone (PTH), cross-linked C-terminal telopeptide of type I collagen (CTX), calcium, and phosphate were measured.

Results

In the 32nd week and the postpartum period, 25(OH) vitamin D3 deficiency rates were 13.3% and 33.3%, respectively. Serum 25(OH) vitamin D3 levels were below the detection limit in 10% and 33%, respectively, of the same subjects. In the control group, rates of 25(OH) vitamin D3 deficiency and “below detection limit” were 30% and 23%, respectively. While 25(OH) vitamin D3 and CTX levels were not correlated to each other in the first trimester, a negative correlation was found in the 2nd and 3rd trimesters and the postpartum period between 25(OH) vitamin D3 and CTX levels (r = −0.472, p = 0.048; r = −0.893, p < 0.0001, r = −0.881, p < 0.001, respectively). No correlation between 25(OH) vitamin D3 and CTX levels was found in controls.

Conclusion

We consider that 25(OH) vitamin D3 supplementation of women could both decrease maternal bone resorption and lead to enhanced bone mass in offspring during later life. Since women are prone to 25(OH) vitamin D3 insufficiency, we suggest higher doses of 25(OH) vitamin D3 should be given to pregnant subjects.     

High prevalence of vitamin D deficiency in Pakistani mothers and their newborns

Objective

To determine the prevalence of vitamin D deficiency in Pakistani parturients and their newborns and to assess the correlation between maternal and newborn serum levels of the vitamin D metabolite 25-hydroxy vitamin D3.

Methods

A prospective study of parturients presenting to the labor suite with a singleton pregnancy. Maternal and cord blood were collected for estimation of serum 25-hydroxy vitamin D3.

Results

In total, 89% of the gravidae were deficient in vitamin D (serum 25-hydroxy vitamin D3 < 30 ng/mL). There was a positive correlation between maternal and cord blood 25-hydroxy vitamin D3 levels(r = 0.68; P < 0.001). Inverse correlations were noted between cord blood 25-hydroxy vitamin D3 and a longer duration of gestation (r = − 0.33; P = 0.003) and with the newborn's birth weight (r = − 0.23; P = 0.048). Maternal 25-hydroxy vitamin D3 levels were inversely correlated with maternal mean arterial pressure (r = 0.029; P < 0.020).

Conclusion

There was a high prevalence of vitamin D deficiency in the Pakistani parturients and their newborns. There was a correlation between higher maternal vitamin D levels and lower blood pressure in the mothers.     

Negative correlation between D-dimer and homocysteine levels during pregnancy and the postpartum period: a prospective study

Objective

There have been conflicting data about the role of increased levels of homocysteine (Hcy) on haemostatic system. We aim to investigate prospectively the relation between serum Hcy levels and changes in haemostatic system in pregnancy and postpartum period.

Study design

Sixty-eight healthy pregnant women were included in the study. Blood samples were obtained in the 11th gestational week, 25th gestational week, 32nd gestational week and postpartum 4th week. The haemoglobin levels, white blood cell count (WBC), platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), fibrinogen, D-dimer, Hcy, vitamin B12, and folate levels were measured.

Results

Serum Hcy levels were negatively correlated with D-dimer levels (r = −0.57, p < 0.0001). The highest levels of D-dimer (1046.62 ± 322.01 ng/ml) were achieved in the third trimester and the lowest levels of serum Hcy (4.45 ± 1.23 mmol/l) were detected in the same trimester. In postpartum fourth week, D-dimer levels were decreased to normal levels (238.27 ± 198.59 ng/ml) while the serum Hcy levels were reached to the highest levels (7.99 ± 1.36 mmol/l).

Conclusion

The negative correlation between Hcy and D-dimer levels may be a compensatory mechanism to maintain the normal haemostatic balance in pregnancy. Hence, possible advantage of low Hcy levels in pregnancy may be to prevent undesired thrombosis.     

A study of maternal mortality in 8 principal hospitals in Pakistan in 2009

Objectives

To determine maternal mortality to assess the achievement of Millennium Development Goal 5 in Pakistan and suggest remedial measures.

Methods

Throughout 2009, maternal deaths occurring in obstetrics and gynecology departments in 8 hospitals in Rawalpindi and Islamabad, Pakistan, were recorded. A data form was filled in by the duty registrar at the time of death. Data were analyzed via SPSS.

Results

During the study period, there were 47 209 live births and 108 maternal deaths (age 17-45 years). Among those who died, 30% were primigravidas, 50% had a parity of 1-4, and 20% had a parity of 5 or more; 20.4% had not delivered, 40.7% had vaginal delivery, and 36.1% had cesarean delivery; 67.6% were unbooked and 32.4% were booked (14 under care of a consultant and 21 under care of a medical officer); 73%, 22%, and 5% died in the first, second, and third trimesters, respectively; 17.5% died prenatally, 4.6% during labor, and 78% postpartum; 73% were in a critical condition and 8% were dead on arrival. Eclampsia, postpartum hemorrhage, and sepsis caused 23, 13, and 13 deaths, respectively.

Conclusion

Maternal death can be effectively managed by skilled care during pregnancy, childbirth, and the postnatal period.     

Elevated glucocorticoid metabolism in placental tissue from first trimester pregnancies at increased risk of pre-eclampsia

Background

The local actions of glucocorticoids in the placenta can be modulated by 11β-hydroxysteroid dehydrogenase (11βHSD) enzymes, which catalyse inter-conversion of cortisol with its inert metabolite, cortisone, and are known to be expressed in the term placenta and decidua. However, the expression and activity of these enzymes have not been well characterised in the first trimester placenta. The aim of this study was to compare 11βHSD2 expression and activity in first trimester placental tissue from pregnancies at either relatively low or high risk of developing pre-eclampsia as determined by Doppler ultrasound.

Methods

Enzyme expression was assessed by western blot analysis and immunohistochemistry while 11βHSD enzyme activities were quantified using radiometric conversion of [3H]-cortisol in the presence of NADP⁺ or NAD⁺.

Results

11βHSD2 was expressed in syncytiotrophoblast of first trimester placenta, and there was no difference in the level of expression of placental 11βHSD2 protein between 9 high pre-eclampsia risk and 14 low pre-eclampsia risk pregnancies. NAD⁺-dependent cortisol oxidation was elevated 3-fold in placental tissue from pregnancies at higher risk of pre-eclampsia than in normal pregnancies (50.9 ± 15.9 versus 18.3 ± 1.9 pmol cortisone/mg protein.10 min, n = 11 & 12, respectively; P < 0.05).

Conclusions

Expression of 11βHSD2 is thought to protect the fetus from exposure to maternal cortisol. While other studies have suggested that 11βHSD2 is down regulated in term pre-eclamptic placentae, our study suggests that there is increased cortisol inactivation in first trimester placenta prior to week 10 of gestation, from pregnancies at higher risk of developing pre-eclampsia.     

SRY-specific cell free fetal DNA in maternal plasma in twin pregnancies throughout gestation

Objectives

Levels of SRY-specific cell free fetal DNA (SRY-cffDNA) in maternal plasma were investigated in twin pregnancies with two male fetuses versus one male and one female fetus and singleton male pregnancies during second and third trimester. The aim was to evaluate at which gestational age the amount of SRY-cffDNA reflects the number of fetuses and placentas respectively.

Methods

251 venous blood samples were analyzed from a total of 178 women with male or mixed-gender twin pregnancies and male singleton pregnancies in the second and the third trimester. The concentration of SRY-cffDNA was determined by quantitative real time PCR using the Y-chromosome specific SRY assay. For statistical analysis these three groups were divided into four subgroups according to their gestational age.

Results

During second trimester levels of SRY-cffDNA showed no differences between twin and singleton pregnancies. After 28 weeks SRY-cffDNA of male twin pregnancies was significantly increased compared to singleton male pregnancies and mixed-gender twin pregnancies with no differences between the latter two.

Conclusion

The level of SRY-cffDNA in maternal serum of twin pregnancies reflects the number of fetuses only during the third trimester. Hence its use as a diagnostic tool for complications related to altered SRY-cffDNA levels in twin pregnancies should be evaluated at different weeks of gestation, especially during the second trimester.     

Thyroid function in the third trimester of pregnancy and after delivery in an area of adequate iodine intake

Objective

To establish whether the higher thyroid stimulating hormone (TSH) levels and lower levels of the 2 free thyroid hormones noted toward the end of pregnancy are in relation with iodine supply.

Methods

We compared these hormones’ levels in the third trimester of pregnancy and 4 months after delivery in 116 consecutive women without thyroid disease and otherwise healthy. The study was conducted in Slovenia, an iodine-sufficient area. The Mann-Whitney test, the Kruskal-Wallis rank test, and Spearman analysis were used for statistical analysis.

Results

In the third trimester TSH was significantly higher and both free thyroid hormones were significantly lower than after delivery (P = 0.003 and P < 0.001), but the free thyroxine to free triiodothyronine ratios in the third trimester and 4 months after delivery did not significantly differ. Urinary iodine concentration (UIC) was significantly higher during pregnancy than after delivery (P = 0.044). We found no significant correlations between UIC and TSH or between UIC and both free thyroid hormones during pregnancy or after delivery.

Conclusion

The decrease of both free thyroid hormones in the third trimester of pregnancy is most likely due to reasons that are not related to iodine supply.     

Four-dimensional sonographic assessment of inter-twin contact late in the first trimester

Objective

To evaluate the total number of inter-twin contacts between monochorionic diamniotic (MD) and dichorionic diamniotic (DD) twins using four-dimensional (4D) sonography late in the first trimester of pregnancy.

Method

Six MD and 8 DD pregnancies were studied for 30 minutes with 4D sonography at 10-11 and 12-13 weeks of gestation. A total of 10 types of inter-twin contact was evaluated.

Results

There was a significant difference in the total number of all contacts between MD and DD twins at the 10-11 weeks of gestation (P < 0.05). There was also a significant difference in the total number of contacts between 10-11 and 12-13 weeks of gestation in DD twins (P < 0.05).

Conclusion

Four-dimensional sonography provides a means of evaluating inter-twin contact in the first trimester of pregnancy and could be an accurate and reliable tool in studies of inter-twin behavior.     

Kurdish pregnant women's feelings: A qualitative study

Objective

to gain a deeper understanding of how Kurdish pregnant women feel about their pregnancy.

Design

a qualitative study analysed by a grounded theory approach.

Setting

the study was conducted among women in the third trimester of their pregnancy in either their homes or the health-care centres in Sanandaj in the western part of Iran.

Participants

22 pregnant women were recruited and interviewed.

Findings

during pregnancy, women experienced a variety of feelings: ‘satisfied and happy’, ‘unpleasant’ and ‘ambivalent’.

Conclusions and implications for practice

it is important for midwives to ask pregnant women about their feelings concerning their current pregnancy, childbirth and future motherhood. If they express negative or ambivalent feelings, these should be discussed in greater detail and their causes identified. Special consideration should be given to primiparous women and multiparous women with negative experiences of previous pregnancies.     

Entrenamiento de equipos interdisciplinares en urgencias obstétricas mediante simulación clínica

Objectives

To describe the healthcare team training in obstetric emergencies using clinical simulation with an interdisciplinary approach, developed at the Hospital virtual Valdecilla.

Material and methods

The program was aimed at health professionals involved in emergency obstetric care (obstetricians and gynecologists, anesthesiologists, intensivists and midwives). A working team was established to define the objectives, design the scenarios, and coordinate the completion of each course. Two simulation rooms were available with patient simulators, control rooms and audiovisual recording systems, an analysis room, a multipurpose classroom, and diverse medical and surgical equipment. To analyze the results of the program, the participants completed an evaluation survey.

Results

A total of 30 members of clinical teams underwent training in the clinical entities most frequently involved in cases of maternal mortality (postpartum hemorrhage, amniotic fluid embolism and eclampsia), selected from the results of a survey of maternal death mailed to 69 Spanish hospitals. Each course consisted of three clinical cases performed in the operating room, postpartum and birthing room, followed by a debriefing session. Participants rated the courses as highly useful, highlighted the opportunity provided by clinical simulation to practice without risk and to train teamwork skills, and would recommend their peers to undergo the same training.

Conclusions

Training of healthcare teams in obstetric emergencies using simulation with an interdisciplinary approach provides safe and effective practice of diagnostic and treatment algorithms, as well as of communication and teamwork skills, before these situations are met in daily practice.     

Cost-effectiveness of misoprostol and prenatal iron supplementation as maternal mortality interventions in home births in rural India

Objective

To determine the cost-effectiveness of prenatal iron supplementation and misoprostol use as interventions to prevent maternal mortality in home births in rural India.

Methods

A cost-effectiveness analysis depicted three hypothetical cohorts of 10 000 pregnant women delivering at home in rural India: one with no intervention, one receiving standard prenatal iron supplements, and 1 receiving 600 µg of misoprostol in the third stage of labor.

Results

Misoprostol used to prevent postpartum hemorrhage resulted in a 38% (95% CI, 5%-73%) decrease in maternal deaths, while prenatal iron supplementation resulted in a 5% (95% CI, 0%-47%) decrease. Misoprostol cost a median US $1401 (IQR US $1008-$1848) prenatal iron supplementation cost a median US $2241 (IQR No Lives Saved-$3882) per life saved compared with the standard care outcome.

Conclusion

Misoprostol is a cost-effective maternal mortality intervention for home births. Iron supplementation may be worthwhile to improve women's health, but it is uncertain whether it can prevent mortality after hemorrhage.     

Routinisation and constraints on informed choice in a one-stop clinic offering first trimester chromosomal antenatal screening for Down's syndrome

Objective

to explore routinisation and constraints on informed choice in a one-stop clinic offering first trimester antenatal chromosomal screening for Down’s syndrome.

Design

recordings of booking appointments and pre-screening consultations in both a community and a hospital clinic setting.

Setting

one antenatal clinic site in the UK offering first trimester nuchal translucency screening in combination with maternal serum screening.

Participants

57 taped clinical consultations involving pregnant women and midwives and health-care assistants (HCAs).

Findings

midwives and HCAs expected women to make informed decisions about screening for Down’s syndrome. However, midwives’ attempts to maintain the normality of pregnancy and avoid discussions about potential scenarios, as well as their emphasis on the high accuracy rate of first trimester screening have routinised first trimester antenatal screening for Down’s syndrome. Also, a general expectation in the clinic to take up screening and the constrained service context in which midwives and HCAs work had implications for women’s informed choices.

Key conclusions

directive information combined with lack of purposeful dialogue with pregnant women have constrained the process of information-giving about antenatal screening for Down’s syndrome.

Implications

the provision of information about antenatal screening for Down’s syndrome is a challenging role for midwives. Changes in midwifery practice resulting from continuing education as well as less constraining service contexts could improve the quality of information about antenatal screening for Down’s syndrome.     

Postpartum depression and traditional postpartum care in China: Role of Zuoyuezi

Objective

To determine the relationship between the traditional Chinese practice of postpartum care, known as zuoyuezi, and postpartum depression (PPD) in China.

Methods

A total of 342 Chinese women were surveyed 6- to 8-weeks post partum using the Edinburgh Postnatal Depression Scale (EPDS) and items assessing sociodemographics, health history, peripartum experiences, zuoyuezi, and social support.

Results

Prevalence of PPD was 15.5% (EPDS cutoff ≥ 13). PPD was associated with lower income, difficult pregnancy experience, poor infant health status, not attending childbirth classes, and low spousal involvement before and after delivery. Among the 96% of women who practiced zuoyuezi, those for whom the caregiver was her mother-in-law or who perceived zuoyuezi as unhelpful had twice the odds of PPD.

Conclusion

These data highlight the importance of the peripartum experience in assessing PPD risk. Zuoyuezi is still commonly practiced in urban China, and further research is needed to explore its role in the potential prevention of PPD.     

Maternal serum protein S forms in pregnancies complicated by intrauterine growth restriction

Objectives

The clinical relevance of protein S deficiency in pregnant women remains controversial. Major debate exists regarding which parameter (total protein S antigen, free protein S antigen or functional protein S) should be evaluated in order to define protein S deficiency. The present study aimed to identify which of these parameters correlate with intrauterine growth restriction (IUGR).

Study design

A retrospective case-control study of women with IUGR (n = 27) and healthy controls (n = 123) in the third trimester of pregnancy.

Results

The maternal serum of women in the IUGR group had significantly lower levels of functional and free protein S compared with the control group: 54.07 ± 24.72% vs 65.20 ± 17.95% (p < 0.005) and 42.88 ± 11.01% vs 56.64 ± 13.30% (p < 0.0001), respectively. No significant correlation was found between total protein S and IUGR.

Conclusions

Levels of functional and free protein S are correlated with IUGR.     

Effects of depression, anxiety, self-esteem, and health behaviour on neonatal outcomes in a population-based Hungarian sample

Objective

To investigate possible associations of maternal antenatal depression, anxiety and self-esteem with negative neonatal outcomes controlling for the effects of demographic covariates and health behaviour in a Hungarian sample.

Study design

A population-based monitoring system was established in 10 districts of health visitors in Szombathely, Hungary, covering every woman registered as pregnant between February 1, 2008 and February 1 2009. Three hundred and seven expectant women in the early stage of their pregnancy were surveyed using the Short Form of Beck Depression Inventory for the measurement of depression and the Spielberger Trait-Anxiety Inventory for the measurement of anxiety. Self-esteem was evaluated by the Rosenberg's Self-Esteem Scale. At the end of the follow-up period, data on 261 mothers and their singleton neonates were available. The relationship between the explanatory and outcome variables (birth weight, length, chest circumference, gestational age, and 1- and 5-min Apgar score) was tested in girls and boys separately by multiple linear regression analysis (Forward method). Categorical variables were used as “dummy variables”.

Results

Maternal depression, anxiety and health behaviour did not show any association with neonatal outcomes. Higher level of maternal self-esteem was associated with higher birth weight and birth length in boys and higher birth length in girls. Maternal education positively correlated with birth length, gestational age and chest circumference in boys, and with birth length in girls. In girls, maternal socioeconomic status showed a positive association with birth weight and gestational age, while common law marriage had a negative effect on birth weight and chest circumference.

Conclusions

Lower level of maternal self-esteem possibly leads to a higher level of maternal stress which may reduce fetal growth via physiologic changes. Gender differences in associations between demographic factors and neonatal outcome measures indicate differences in fetal development between boys and girls.     

Crying babies, tired mothers: What do we know? A systematic review

Objective

to synthesise the evidence on the interconnectedness of infant crying and maternal tiredness in the postpartum period, both from quantitative as well as from qualitative studies.

Methods

a systematic review was conducted including studies in English, French and German published from 1980 to 2007. Studies were included in the systematic review if they had extractable data on infant crying as well as maternal tiredness in the period of 0-3 months post partum. Of 100 retrieved publications, 10 met these criteria.

Findings

evidence from this review indicated that the amount of infant crying during the first three months postpartum is associated with the experience of tiredness and fatigue in new mothers. Significant associations were found in five of six quantitative studies. The four identified qualitative studies describe how infant crying disrupts new mothers’ circadian rhythms, reducing opportunities to rest and exacerbating tiredness. Incremental exhaustion diminished parents’ ability to concentrate, raising the fear of harming their children, triggering depressive symptoms and burdening parent-child interaction.

Key conclusions and implications for practice

if healthcare professionals are to address the prominent concerns of parents caring for a neonate, it is essential to review current care practices and tailor them to maternal and infant needs. A care strategy alleviating the burden of infant crying and maternal fatigue has the potential to strengthen family health from the earliest stage.