South African Journal of Obstetrics and Gynaecology

Comparison of obstetric and perinatal outcomes in women with diabetes at Steve Biko Academic Hospital

N. Malaza — 2024-01-29

Background: Diabetes and obesity in pregnancy have been associated with increased rates of adverse maternal and neonatal outcomes compared with women with normoglycaemia and normal weight.

Objective: To investigate the effect of diabetes and pre-pregnancy obesity on obstetric and perinatal outcomes.

Methods: This study included women with pregestational diabetes types 1 (T1DM) and 2 (T2DM), gestational diabetes (GDM) and normoglycaemia, who received care at the Steve Biko Academic Hospital antenatal clinic between 2017 and 2022. The women were followed up until delivery. Data collected included obstetric history and care, diabetes, obstetric and perinatal outcomes

Results: A total of 183 women were recruited: 13 (7.1%) with T1DM, 65 (35.5%) with T2DM, 39 (21.3%) with GDM and 66 (36.1%) normoglycaemic controls. Women with T2DM and GDM were older (p<0.01) and more likely to have a history of chronic hypertension (p=0.025) compared with controls. Women with GDM were more likely to be obese than their T1DM counterparts (p=0.036). T1DM and T2DM were associated with higher rates of preterm delivery than controls (p=0.002). The frequency of GDM was significantly higher in women with obesity (p=0.039). The frequency of caesarean section before the onset of labour was higher in women with a weight ≥80 kg compared with women with a weight <80 kg (p=0.015).

Conclusion: Diabetes in pregnancy is associated with adverse obstetric and perinatal outcomes. Therefore, adequate glucose control should be accompanied by preconceptual weight optimisation to reduce adverse outcomes during pregnancy.

The safety and efficacy of immediate post-placental IUD insertion versus the post-puerperal IUD insertion in women undergoing caesarean delivery

M.A.M. Dawoud — 2024-01-29

Objective: To assess the safety and efficacy of immediate intrauterine contraceptive copper device (IUD) insertion following delivery of the placenta in women undergoing caesarean delivery.
Methods: In this randomised clinical trial, 66 women were evenly divided into two arms, with 33 patients in each arm. The first group had an IUD inserted 10 minutes after delivery of the placenta (post-placental group), while the second group had their IUD inserted at 6 weeks following delivery (interval group).
Results: The complication rate for post-placental IUD insertion was comparable with that of interval insertion. The expulsion and displacement rates were similar for both post-placental and interval groups at the 6-week and 3-month follow-up.
Conclusion: Post-placental IUD insertion is a safe and attractive option for postpartum contraception that should be offered to all women undergoing elective caesarean section after proper counselling.

The incidence of clinically impactful postoperative nausea and vomiting after spinal anaesthesia for caesarean section in an academic hospital

C. Ogunjiofor — 2024-01-29

Background: Postoperative nausea and vomiting (PONV) are common side-effects following administration of spinal anaesthesia for
caesarean section (CS). PONV is reportedly perceived to be more distressing than pain by patients, which necessitates assessment of its
incidence to ensure that it is not undertreated and that effective measures are undertaken to address it.

Objectives: To study the incidence of PONV and associated factors in patients delivering via CS.

Methods: A total of 308 healthy parturients undergoing CS under spinal anaesthesia were recruited. This was a single-centre prospective observational study conducted at an academic hospital. The institution standard of practice for spinal anaesthesia for CS was employed and consisted of injecting 1.8 - 2.0 mL of hyperbaric bupivacaine 0.5% solution plus 10 µg fentanyl at the L3/L4 interspace after preloading the patient with intravenous fluid 10 - 15 mL/kg. Phenylephrine boluses were used in managing any spinalinduced hypotension according to standard protocol. The demographic data and patient characteristics were recorded. Complaints of PONV were recorded postoperatively in the recovery room and 3 hours after the procedure. The clinical significance of PONV was assessed using the PONV impact scale.

Results: Of the 308 enrolled patients, 295 (95.8%) were black, 9 (2.9%) coloured and 4 (1.3%) white. The overall incidences of nausea and vomiting were 2.6% and 9.7%, respectively, with all episodes occurring during the first 3 hours after the procedure. The overall incidence of PONV was 10.1%. The odds of experiencing PONV for patients with increased birth weight, lowest blood pressure and Apfel score <3 were 1.0 (95% confidence interval (CI) 0.99 - 1.00), 1.01 (95% CI 0.98 - 1.04) and 0.35 (95% CI 0.11 - 1.12), respectively. There was no report of clinically significant PONV.

Conclusion: The overall incidence of PONV in this study was 10.1%, and there was no clinically significant PONV.

The association of fetal macrosomia and neonatal hypoglycaemia

T.R. Moodley — 2024-01-29

Background: The clinical management of fetal macrosomia in pregnant women poses a challenge for obstetricians globally. This has become increasingly important in recent times due to the rising incidence of this condition and its associated risks to both the mother and infant, including birth injuries and neonatal hypoglycaemia.

Objective: To investigate the association between neonatal hypoglycaemia and fetal macrosomia in a cohort of South African black non-diabetic women.

Methods: This retrospective study analysed the clinical outcomes of 415 macrosomic babies born to non-diabetic women between 2015 and 2016 at a regional hospital in Durban, South Africa.

Results: Of the 415 macrosomic babies, 52 had hypoglycaemia (<2.6 mmol/L). The prevalence rate of neonatal hypoglycaemia was therefore 12.53%.

Conclusion: Neonatal hypoglycaemia is a common complication in babies with macrosomia born to black non-diabetic South African pregnant women.

The clinical significance of placental histopathological evaluation in the management of high-risk obstetric patients: A cross-sectional retrospective study

R. Stevens — 2024-01-29

Background: Placental pathologies cause significant morbidity for both mother and fetus, and represent the largest category of causes of intrauterine death. Placental histopathology allows for recognition of treatment opportunities to prevent recurrence of adverse outcomes.

Objectives. To determine the indications for and findings of placental histopathological evaluation and assess the clinical use of the findings in the management of high-risk obstetric patients. A secondary objective was to compare placental histopathological findings of patients with and without pre-eclampsia.

Methods. A cross-sectional retrospective study was performed at Charlotte Maxeke Johannesburg Academic Hospital, South Africa, on patients who had placentas submitted for histological evaluation at the time of delivery (1 June 2018 - 31 May 2019). The clinical indications, histopathology results and proposed follow-up plan in view of those results were analysed.

Results. We assessed 176 placental histopathology reports and hospital records. The most common indications were stillbirth (50.0%), pre-eclampsia (31.1%), late miscarriage (21.6%) and severe fetal distress (15.9%). The most common individual microscopic findings were increased syncytial knots (52.8%), patchy perivillous fibrin (48.9%) and chorioamnionitis (40.3%). The most common cluster diagnoses were maternal vascular malperfusion (51.1%) and ascending infection (35.8%). Of our patient cohort, 55.7% received a follow-up appointment date and 44.3% did not, and 65.3% of patients with a follow-up appointment did not attend it. A management plan for future pregnancies was formulated for only 52.9% of those who attended their follow-up appointment. While statistically significant individual microscopic features were noted in cases of pre-eclampsia, the most important associations were identified between cluster diagnoses such as maternal vascular malperfusion and pre-eclampsia (p<0.0001) and ascending infection and pre-eclampsia (p=0.003).

Conclusion. This study showed that histopathology results are underutilised in formulating future management plans. In high-risk obstetric patients, management options for pregnancies must include review of previous placental histopathology results to prevent further adverse outcomes.

Post-caesarean section outcomes of obstetric patients with valvular heart disease at Charlotte Maxeke Johannesburg Academic Hospital, South Africa

Z. Mfeka — 2024-01-29

Background: Valvular heart disease presents a unique set of conditions during pregnancy and delivery, with the potential for adverse
outcomes increased by prior interventions and anticoagulation.
Objectives: To describe the profile and outcomes of obstetric patients with valvular heart disease who delivered via caesarean section at
Charlotte Maxeke Johannesburg Academic Hospital, South Africa.
Methods: A 5-year retrospective descriptive cross-sectional study was performed. All patients with valvular heart disease who
underwent caesarean section, irrespective of age, were included. Exclusion criteria were absence of important clinical data relevant
to the study and outcomes data. All records of patients who delivered by caesarean section and were booked in the obstetric cardiac
unit were reviewed. Data for those who had valvular heart disease were separated from non-valvular heart disease data. A total of
69 patients were included in the analysis. Univariate logistic regression analysis was done to assess the predictors of maternal and
fetal outcomes.
Results: The mean (standard deviation) age of the patients in the study was 30.1 (5.6) years, 82.6% were gravida 1 - 3 and 89.8% para
0 - 2, and the majority (56.5%) had an elective caesarean section. General anaesthesia was the most common mode used, and most of
the patients had fixed-interval analgesia postoperatively. Approximately two-fifths of the patients (n=28; 40.6%) were on anticoagulants.
A significantly higher percentage of those who were on anticoagulants had complications (n=12/28; 42.9%) compared with those who were not on anticoagulants (n=3/41; 7.3%) (p<0.001). There was a total of 19 complications, mainly bleeding (n=7) and cardiac arrhythmias (n=6). New York Heart Association class and use of anticoagulants were individually associated with adverse maternal outcomes after univariable logistic regression analysis (p=0.006 and p=0.017, respectively). In univariable logistic regression analysis, a low ejection fraction was associated with adverse fetal outcome (odds ratio 0.94; 95% confidence interval 0.90 - 0.99; p=0.032). One infant (1.4%) died, in the early neonatal period.
Conclusion: Pregnancy in women with cardiac disease is possible, but it is not without risk, and a structured plan and multidisciplinary team approach to provide prehabilitation is therefore necessary. Our patients were young and with relatively good functional status (metabolic equivalent >4), and most pregnancies continued to term or early term (median (interquartile range) 37 (36 - 38) weeks). Some patients experienced adverse outcomes, mainly related to bleeding and arrhythmias, but none died. There was one early neonatal death. These patients need a structured multidisciplinary team care plan.