Perinatal health in the peri-urban township of Khayelitsha, Cape Town. Part II. Infant mortality

Estimates of infant mortality suggest that the rate during the past 14 years for families living in Khayelitsha at present was approximately 130-160/1,000. In contrast, the infant mortality rate for infants born in Khayelitsha during 1986 was 50.3/1,000. The highest rates occurred in the post-neonatal period in 'squatter' families, infection being a common cause of death. Mortality rates should fall further with improved housing.     

妊娠期甲状腺功能亢进症和抗甲状腺药物治疗对新生儿低出生体重的影响

目的探讨妊娠期间甲状腺功能亢进症(甲亢)和抗甲状腺药物(ATDS)治疗对新生儿低出生体重(LBW)的影响。方法对1983年1月1日至2003年12月31日住院分娩的妊娠合并甲亢的100例及其新生儿101例进行回顾性分析。根据母亲孕期甲状腺功能(甲功)、开始服用ATDs时间进行分组,对LBW的发生率、特点及其相关的危险因素进行分析,着重于妊娠甲亢和ATDs对LBW的交互作用。结果母亲孕晚期甲亢时,新生儿平均出生体重显著低于甲功正常和甲功恢复正常组(P<0.05);孕晚期开始服用ATDs,新生儿平均出生体重显著低于孕早中期开始用药组(P<0.001)。孕晚期甲亢、孕晚期开始服用ATDs早产儿和早产LBW率均显著增加,且二者对早产儿、早产儿LBW存在正交互作用(L.R Chisq为19.328和7.486,P=0.0001和0.0237)。孕晚期甲亢和孕晚期开始服用ATDs,发生LBW、早产儿和早产LBW的危险性显著增加。结论妊娠期间甲亢,特别是孕晚期甲亢和孕晚期才开始ATDs治疗,可导致LBW,尤其是早产LBW率增加。     

Births and perinatal deaths in Mitchell's Plain

All births and perinatal deaths from Mitchell's Plain, Cape Town, during the first 8 months of 1985 were analysed. Out of a total of 4,228 liveborn infants 66.4% were delivered by the Peninsula Maternity and Neonatal Service (PMNS), while the remaining 33.6% were born to private patients. There was an overall preterm rate of 11.0%, while 13.8% of infants had a birth weight of less than 2,500 g. Only 16.1% of mothers booked early. The perinatal mortality rate was 22.2/1,000 and the stillbirth rate 12.6/1,000. The stillbirth rate for private patients was more than 6 times lower than that for their PMNS counterparts (2.8 v. 17.5/1,000).     

Effect of stress on birth weight in two Johannesburg populations

The effect of stress on birth weight was assessed in mothers delivering at Johannesburg (predominantly white) and Baragwanath (exclusively black) Hospitals. The Social Readjustment Rating Scale of Holmes and Rahe was used to assign maternal stress scores established during an interview conducted within 36 hours of delivery. Only mothers without medical problems who had delivered liveborn infants were included. Maternal age, obstetric history, smoking history and stresses present during the 12 months preceding delivery were recorded. Of 535 Johannesburg and 662 Baragwanath mothers studied, 48% and 55% respectively reported significant stresses. Analysis of the two groups revealed that for the Johannesburg mothers, smoking, cumulative stress score and previous preterm birth were important determinants of birth weight. Of the stress factors studied, marital separation and death of a spouse were significantly associated with a lower birth weight. For Baragwanath mothers the major determinants of low birth weight were maternal age, loss of income through being dismissed from work, or having to leave school as a consequence of the pregnancy.     

Outcome of pregnancy in women with cystic fibrosis.

BACKGROUND--As women with cystic fibrosis are living longer, pregnancy is becoming increasingly common. The combined experience of pregnancies in women with cystic fibrosis from adult centres in the Midlands and North of England has been examined. METHODS--A retrospective study of the case notes of 22 pregnancies in 20 patients with cystic fibrosis examined changes in lung function, body weight, and microbiological status during the course of pregnancy. Duration of pregnancy, birth weight, and maternal survival were amongst other variables studied. The relation between values before pregnancy and important outcome measures were examined. RESULTS--Eighteen of 22 pregnancies were completed producing healthy, non-cystic fibrosis infants (12 female). Mothers lost 13% of FEV1 and 11% of FVC during pregnancy, most of which was regained. Body weight changes were variable, but most mothers gained weight (mean weight gain 5.7 kg). Microbiological status remained unchanged. Six infants were preterm and two were light for dates. Four mothers died up to 3.2 years following delivery. Of the prepregnancy parameters examined, %FEV1 showed the best correlation with maternal weight gain, gestation, birth weight, and maternal survival. CONCLUSIONS--Pregnancy was well tolerated by most mothers with cystic fibrosis although those with moderate to severe lung disease (%FEV1 < 60%) before pregnancy fared worse, producing preterm infants and suffering increased loss of lung function and mortality compared with mildly affected mothers. Prepregnancy %FEV1 appears to be the most useful predictor of important outcome measures in pregnancies in women with cystic fibrosis.     

Birth weight and creatinine clearance in young adult twins: influence of genetic, prenatal, and maternal factors

Previous studies have shown that low birth weight (LBW) is a risk factor for renal impairment in adult life. The effects of LBW and renal function were studied by using twins, which allows distinguishing among fetoplacental, maternal, and genetic influences. Perinatal data were obtained at birth, and absolute creatinine clearance (not corrected for body surface area) was measured at a mean age of 25.6 yr in 653 individuals. Twins were considered both as individuals and as members of twin pairs. Statistical analyses were performed with and without adjusting for gestational age, zygosity, gender, age, body mass index, glucose level, BP, and smoking status. Creatinine clearance was 4 ml/min lower in twins with LBW (<2500 g) than in twins with a high birth weight (P < 0.04, adjusted). Intrapair birth weight difference correlated positively with the intrapair difference in creatinine clearance equally in monozygotic and dizygotic twins (r = 0.35, P < 0.0001; r = 0.43, P < 0.0001, respectively). This suggests that fetoplacental factors are related to renal function and that genetic factors are less important. There was no significant difference in creatinine clearance between twins who both had LBW as compared with twins who both had a high birth weight. This may suggest that maternal factors, which influence the relation between LBW and renal function, are less important. LBW is related to a lower creatinine clearance at adult age. This relationship is probably due to fetoplacental factors. Surprising, genetic and maternal factors seem less important.     

Relationship between weight at birth and the number and size of renal glomeruli in humans: a histomorphometric study

BACKGROUND: The number of nephrons in humans varies considerably under normal circumstances, and retarded intrauterine growth has been reported to be associated with a significant reduction in nephron number. Low nephron number may be an independent risk factor for the development of hypertension. We therefore decided to evaluate the relationship between body weight at birth and the number and size of nephron units. METHODS: We examined coronal sections of the kidneys of 35 neonates who died within two weeks of birth because of hyaline membrane, infectious complications, brain hemorrhage, or perinatal hypoxia and had no urinary congenital malformations. Nine of them (5 males and 4 females) were between 36 and 37 weeks of gestation, and the rest had 38 or more weeks of gestation. Eighteen neonates weighed less than 2500 g at birth [low birth weight (LBW); 9 females and 9 males], and 17 had weights above this value [normal birth weight (NBW); 8 females and 9 males]. In each section, glomeruli present in four sequential subcapsular microscopic fields, corresponding to 0.6 mm2, were counted; in addition, the area of each of 65 consecutive glomeruli was determined by a computerized measurement system. Glomerular volume was calculated from the glomerular area. Linear regression analysis was used to test the relationship between glomerular number and size and the weight at birth. RESULTS: The number of glomeruli per 0.6 mm2 of renal cortex was 92.9 +/- 4.85 in the LBW and 105.8 +/- 3.91 in NBW (P < 0.0001). Glomerular volume (micro(3) x 10(-3)) was 529.1 +/- 187.63 in the LBW group and 158.0 +/- 49.89 in the NBW group (P < 0.0001). The glomeruli occupied 8.59 +/- 1.38% of the kidney area under examination in the LBW group and 14.3 +/- 2.75% in the NBW group (P < 0.0001). There were significant direct correlations between the weight at birth and the number of glomeruli (r = 0.870, P < 0.0001) and area occupied by glomeruli (r = 0.935, P < 0.0001). There were inverse correlations between the number of glomeruli and the volume of the glomeruli (r = -0.816, P < 0.0001) and the weight at birth and glomerular volume (r = -0.848, P < 0.0001). These findings were independent of sex and race (black vs. white). Essential arterial hypertension existed in 38.9% of the mothers of children with LBW and in 5.9% of the mothers of children with NBW (P < 0.05). Smoking habits existed in 50% of the mothers of LBW children and in 11.8% of the mothers of NBW children (P < 0.05). CONCLUSION: There are strong correlations between glomerular number (direct) and size (inverse) with LBW in this cohort. Endowment with decreased nephron numbers may be a risk factor for hypertension and the rate of progression of renal disease.     

Survival of low-birth-weight infants at Baragwanath Hospital--1950-1996.

OBJECTIVES: To examine changes in survival rates among low-birth-weight (LBW) infants between the years 1950 and 1996. METHODS: Survival figures were analysed for LBW infants managed at Baragwanath Hospital, a tertiary care centre in Soweto, Johannesburg, over four periods spanning five decades. RESULTS: The overall mortality rates of LBW infants decreased markedly between the early 1950s and the period 1995/96. By the mid-1990's approximately four times the number of infants with birth weight less than 1,500 g were surviving compared with the early 1950s. The reduction in mortality rates occurred in all LBW groups during the first three decades. However, since 1981 infants who weighed less than 1,500 g at birth were the major contributors to the overall reduction in mortality. Between the years 1981/82 and 1995/96, survival increased significantly from 64% to 79% for infants with birth weight 1,000-1,499 g, and from 14% to 32% for those with birth weight less than 1,000 g. Since infants in the latter group were seldom offered mechanical ventilation or artificial surfactant, a large part of these increases in survival can be attributed to improvement in the general level of care. CONCLUSION: There have been dramatic improvements in the survival of LBW infants over this time period at Baragwanath Hospital. Although newer interventions such as mechanical ventilation and artificial surfactant have played a significant role, improvement in care at primary and secondary levels has been of major importance.     

Trends in maternal mortality in Cape Town, 1953-1977

In the period 1953 - 1977 there were 223 maternal deaths among 291 800 patients delivered in hospitals under the aegis of the Department of Obstetrics and Gynaecology of the University of Cape Town. A sudden decrease in the maternal mortality rate to below 100/100,000 deliveries occurred in 1956, largely due to the greater use of the obstetric 'flying squad'. Since 1975 maternal mortality rates have been available for the various ethnic groups. For the period 1975 - 1977 the rates were 69/100,000 for Blacks, 40/100,000 for Coloureds and 27/100000 for Whites. Of the deaths, 48% occurred in women aged 21 - 30 years and 29% in those aged 35 years or more. While 28% of deaths were associated with the first pregnancy, grand multiparity (parity 5 or more) accounted for 39%. Nearly half of the patients who died were unbooked. The 7 commonest causes (grouped) of maternal deaths (obstetric as well as non-obstetric) were, in rank order: proteinuric hypertension, haemorrhage, cardiac disease, pulmonary embolism, sepsis, trauma and anaesthetic complications. Proteinuric hypertension is the most important obstetric problem in Cape Town, in terms of numbers of patients, maternal and perinatal deaths, and socio-economic implications for the community. Slightly more than 33% of the infants whose mothers died also succumbed. Major avoidable factors associated with maternal deaths were booking status, grand multiparity, cardiac disease and late or incorrect use of the 'flying squad'.     

Low birth weight for gestation and airway function in infancy: exploring the fetal origins hypothesis

BACKGROUND: Poor fetal growth has been associated with impaired airway function in adult life, but evidence linking birth weight and airway function in early childhood is sparse. We examined the hypothesis that low birth weight for gestation is associated with impaired airway function shortly after birth and that this is independent of impaired postnatal somatic growth. METHODS: Airway function was measured using the raised volume technique in healthy white infants of low (< or =10th centile) or appropriate (> or =20th centile) birth weight for gestation and was expressed as forced expiratory volume in 0.4 s (FEV0.4), forced vital capacity (FVC), and the maximal expired flow at 25% of forced vital capacity (MEF25). Infant length and weight, maternal height and weight, maternal report of smoking prenatally and postnatally, and parental occupation were recorded. RESULTS: Mothers of low birth weight for gestation infants (n=98) were lighter, shorter, and more likely to smoke and have partners in manual occupations. At 6 weeks their infants remained lighter and shorter than those of appropriate birth weight (n=136). FEV0.4, FVC, and MEF25 were reduced in infants of low birth weight for gestation, in those whose mothers smoked in pregnancy, or who were in manual occupations. After adjusting for relevant maternal and infant characteristics, infants in the low birth weight for gestation group experienced a mean reduction of 11 ml in FEV0.4 (95% CI 4 to 18; p=0.002), of 12 ml in FVC (95% CI 4 to 19; p=0.004), and of 28 ml/s in MEF25 (95% CI 7 to 48; p=0.03). CONCLUSIONS: Airway function is diminished in early postnatal life as a consequence of a complex causal pathway which includes social disadvantage as indicated by maternal social class, smoking and height, birth weight as a proximal and related consequence of these factors, and genetic predisposition to asthma. Further work is needed to establish the relevance of these findings to subsequent airway growth and development in later infancy and early childhood.     

Neonatal effects of patient-controlled analgesia using fentanyl in labor

Patient-controlled analgesia (PCA) has been used at our institution for the past 5 years, as an alternative labor analgesic when epidural analgesia is contraindicated. This retrospective study evaluates the effects of maternal PCA fentanyl on infants of greater than 32 weeks gestational age. The neonatal charts (n=32) were reviewed for birth weight, gestational age, 1 min and 5 min Apgar scores, use of naloxone and umbilical venous gases. Infants requiring naloxone were defined as narcotized. Results from narcotized and non-narcotized neonates were compared with the Wilcoxon two-sample test. Fourteen infants had a 1 min Apgar score or= 7, except in the three infants who had received naloxone. Gestational age, birth weight, method of delivery, PCA duration, time from last dose to delivery, total fentanyl used and rate of fentanyl infusion were not predictive of low 1 min Apgar scores. Three infants with a 1 min Apgar of 4 required naloxone. The total fentanyl received by mothers of infants who required naloxone was significantly higher than the group of mothers whose infants did not require naloxone (770 +/- 233 microg vs 298 +/- 287 microg, P = 0.027) Use of PCA fentanyl in this high-risk obstetric population was associated with a 44% incidence of moderately depressed neonates with an Apgar score 相似文献   

Pregnancy after Lap-Band Surgery: Management of the Band to Achieve Healthy Weight Outcomes

Background: Severely obese women have higher obstetric risks and poorer neonatal outcomes. Weight loss reduces obstetric risk. The introduction of a laparoscopically-placed adjustable gastric band, a safe and effective method of weight loss, has given us the ability and responsibility to adjust the band in relation to pregnancy. Objective: Our aim was to devise a safe management plan to achieve healthy maternal weight gain (Institute of Medicine 1990) during pregnancy. Methods: In a cohort group of 650 patients to have a Lap-Band? placement for severe obesity, we have reviewed the management of the band and pregnancy outcomes of all women (n=20) to complete a pregnancy (n=22) with a band in-situ. Results: All 22 pregnancies were singleton, with no primary caesarean sections (3 for recurring indications). The mean maternal weight gain was 8.3 kg compared with 15.2 kg for the 15 previous pregnancies of women in this group (p<0.05). There was no difference in birth weights. Obstetric complications were minimal, and there were no premature or low birth weight infants. 11 of 15 subjects with active management of the band achieved a maternal weight gain within the advised range compared with only 2 of 7 prior to this. Conclusion:The ability to adjust gastric restriction allows optimal control of maternal weight change in pregnancy and should help avoid the risks of excessive weight change.     

Prediction of intra-uterine growth retardation using maternal glucose tolerance and anthropometric data

Maternal anthropometric data and the intravenous glucose tolerance test (IVGTT) were investigated as predictors of idiopathic intra-uterine growth retardation (IUGR). Eighty-three eligible subjects without known risk factors for IUGR were enrolled at 30.5 +/- 3.8 weeks' gestation and followed up until delivery at 39.3 +/- 1.9 weeks, at which stage the infants were assessed. There were no differences between the IVGTT profiles of mothers of infants which were appropriate for gestational age and those which were small for gestational age (SGA), irrespective of lenient or strict definitions of SGA. Third-trimester weight gain (grams per week) correlated well with both duration of pregnancy and birth weight (P less than 0.01). Correlations were also found between maternal weight and birth weight, between maternal height/weight ratio and birth weight, and between birth weight and maternal subscapular skinfold thickness.     

The unbooked mother at Tygerberg Hospital. A prospective controlled study

A prospective controlled study was carried out at Tygerberg Hospital to ascertain the difference between booked and unbooked mothers with regard to social and medical aspects and knowledge of the medical system. Thirty unbooked mothers were compared with 77 booked mothers. The general picture that emerged was that the unbooked mother is young, unmarried and unemployed, has a low income and has no permanent relationship with the father of the infant. However, she knows where the antenatal clinic is and that she should and when she should attend. The reasons for not attending were non-specific. There was no difference between the two groups as regards level of education. The obstetric complications in the unbooked group were premature labour, premature rupture of the membranes and intra-uterine death. These did not occur in the control group. It is suggested that an important difference between booked and unbooked patients is personality and attitude towards pregnancy and parenthood.     

Low-birth-weight infants in the Cape Peninsula. A follow-up study at the age of 3 years

A sample of coloured children from the Cape Town City Council area who had been of low birth weight, although a weight appropriate for gestational age, was examined at the age of approximately 3 years. The children were compared with a control group of similar social background who had been of normal birth weight. Growth parameters were compared with the National Center for Health Statistics centiles. The low-birth-weight infants had compensated well. Although they were lighter, shorter in stature and had lower intelligence quotient scores than their normal-birth-weight contemporaries, when corrected for prematurity the growth parameters and IQ did not differ significantly from those of the controls. Six per cent of the preterm infants had major and 15% minor handicaps. Infants with very low birth weights (less than 1500 g) had no more handicaps than those with low birth weights. Iron deficiency was detected in 18% of the children overall but all those who were anaemic were from the low-birth-weight groups. Between 1 and 3 years of age the low-birth-weight infants had more illnesses but no more hospital admissions than the controls.     

Effect of a mother-to-child HIV prevention programme on infant feeding and caring practices in South Africa.

OBJECTIVES: To conduct a rapid assessment of the impact of the Khayelitsha Prevention of Mother-to-Child Transmission (MTCT) programme on infant care practices among programme participants and the local population. STUDY DESIGN: Cross-sectional survey and qualitative in-depth interviews. SETTING. Khayelitsha, a large formal and informal settlement of about 300,000 people on the outskirts of Cape Town. At the time of the study the HIV seroprevalence rate among antenatal women was about 15% and the MTCT programme had enrolled nearly 800 infected women. SUBJECTS: Seventy randomly selected caregivers with young children in the survey; in-depth structured interviews with 11 nutrition counsellors and 11 mothers enrolled in the programme. RESULTS: Caregivers have good knowledge of the spread and prevention of HIV. A majority knew that breast-feeding can transmit HIV but 90% stated that this did not affect their feeding decisions. Over 80% had stopped exclusively breast-feeding by the time their infants were 3 months of age. All of the respondents felt that being diagnosed HIV-positive would result in serious social and domestic consequences. None of the health workers could correctly estimate the risk of spreading HIV through breast-feeding and many reported feeling confused about what they should counsel mothers. All the mothers on the programme reported exclusive formula-feeding. Some had serious problems with preparation and feeding of formula milk. Nearly all reported running out of feeds before being able to fetch new supplies. None reported any negative social effects of not breast-feeding. Most of the mothers endorsed the programme and felt that it had given them strength to face up to and plan for the consequences of their diagnosis. CONCLUSION: This rapid appraisal of the infant feeding and care component of the MTCT programme has raised a number of important challenges which health managers and policymakers need to address. Similar assessments in the new pilot sites will be important.     

Neonatal pancreatic function in infants born to mothers with gestational and overt diabetes

Neonatal pancreatic function was assessed in infants born to non-diabetic mothers and to mothers with well-controlled gestational diabetes (GD) and overt diabetes (OD) using cord blood C-peptide estimations and the calculation of cord C-peptide/glucose ratios. Exaggerated pancreatic function was present in infants born to mothers with GD. In these infants the increased cord C-peptide values and cord C-peptide/glucose ratios correlated with their increased birth weight ratios. These results could not be explained on the basis of maternal hyperglycaemia and a possible intrinsic difference in pancreatic response between infants born to mothers with GD and those born to mothers with OD is suggested.     

High plasma norepinephrine concentrations at birth in infants of diabetic mothers.

Analysis of plasma norepinephrine (NE) concentrations in umbilical artery and vein from infants of diabetic and nondiabetic mothers revealed high plasma NE values in those of diabetic mothers. While birth weight and arterial plasma NE did not correlate in infants of nondiabetic mothers (r = 0.07, NS), birth weight and plasma NE were related inversely in infants of diabetic mothers (r = -0.73, P less than 0.05).     

Rate of change of blood pressure in premature and full term infants from birth to 4 months

Systolic and diastolic blood pressures were evaluated in a cohort of 61 non-hypertensive premature [very low birth weight (VLBW),n=16; low birth weight (LBW),n=22] and full-term [normal birth weight (NBW),n=23] newborn infants admitted to a neonatal intensive care unit (NICU) and followed to their 4-month age-adjusted outpatient examination. All were receiving routine postnatal care by 7 days of age. Blood pressure was measured at 7 days of age, at discharge from the NICU, and at the outpatient examination. Simple linear regression of blood pressure on weight was used to fit a straight line to the three measurements for each infant and the average regression line for each birth weight group was then obtained. There was a significant correlation between systolic blood pressure and both weight and length at each of the measurement points and also between the change in systolic, blood pressure and change in weight from the discharge to the 4-month examination. Diastolic blood pressure tended to follow this same pattern. Gestational age was correlated significantly with the 7-day blood pressure, but postnatal age at the outpatient examination was not correlated with either systolic or diastolic blood pressure. The average slopes of systolic and diastolic blood pressure on weight (mmHg/kg body weight) were virtually identical for the LBW and NBW groups; in constrast, the average slope of the VLBW group was greater than the other two groups, and the difference was statistically significant for diastolic blood pressure. These results show significant group differences in mean blood pressure prior to 4 months of age between VLBW, LBW, and NBW groups and, for the VLBW infants, a steeper slope of the estimated regression line of blood pressure on weight between birth and 4 months.