Editor’s Note

FETAL HEART RATE MONITORING: DOES IT COUNT? A Jagau 202

THE EFFECTS OF ECONOMIC DISPARITY AND DEPRESSION DURING PREGNANCY ON MATERNAL PHYSIOLOY AND INFANT BIRTH WEIGHT (ABSTRACT). WP Fifer 207

AUDIT OF ANTENATAL CLINIC FIRST VISITS IN JOHANNESBURG 2013
E Buchmann, N Lembethe, M Makgotlhoe, M Maseleni

Johannesburg District Clinical Specialist Team

Introduction

Early first-visit pregnancy attendance (booking) at antenatal clinic offers opportunities for detection of problems that may affect pregnancy outcome, such as anaemia, hypertension and HIV. A national goal in South Africa is that at least 50% of women should attend antenatal clinic before 20 weeks’ gestation. Johannesburg district fall short of this goal, with only 38% of antenatal first visits occurring before 20 weeks’ gestation. This audit was done from August to October 2013 to understand the process of antenatal first visits in Johannesburg and to identify possible barriers to early antenatal booking.

Setting and methods

In Johannesburg, there are 118 public service antenatal clinics (82 municipal, 21 provincial at clinics, 10 provincial at community health centres (CHCs), and 5 at hospitals) in seven sub-districts. About 80 000 women book at antenatal clinics each year, just under half at municipal clinics. This audit was done by using random sample of 20 antenatal clinics, stratified by type of clinic (10 municipal clinics, 5 CHCs, and provincial clinics) and sub-district (all sub-districts represented, proportionate to size of population). Permission to undertake the audit was obtained from the management of the clinics. A midwife or doctor from the district clinical specialist team (DCST) visited each clinic and interviewed the midwife in charge of the antenatal clinic about how antenatal first visits are managed. Then, the DCST member interviewed a convenience sample of 16 women from the antenatal clinic queue, asking them questions about how and when they discovered they were pregnant and their experience with booking for antenatal care.

Results

Eleven of the 20 clinics, which included all 10 municipal clinics, had only one examination cubicle for antenatal care. Six antenatal clinics had 3 or more cubicles. Most antenatal clinics accepted first visits on only certain days of the week, with 8 (including 7 municipal clinics) setting aside only one day a week. Five antenatal clinics accepted first visits on all weekdays. None offered weekend antenatal care. Midwives at four of the clinics stated that they sometimes turned pregnant women away when attempted to initiate antenatal care. The staff allocated to antenatal care was 1 midwife in 5 antenatal clinics, 2 midwives in 5 antenatal clinics, and 3 or more midwives in 10 antenatal clinics. Nine of the antenatal clinics received no allocation of enrolled or assistant nurses. Regarding paperwork, the reported number of documents and forms required for antenatal first visit care varied from 1 to 9, with a median of 6. The most frequently required documents that had to be completed were the antenatal cared, the antenatal register, the FDC register, the daily statistics sheet, the blood tests book, the IPT book, the yellow file for ART, blood forms, and the BANC check-list.

Of the 320 pregnant women interviewed, at a median of 6 months’ gestationa, 35% were nulliparous. The median gestational age at which they said they found out they were pregnant was 2 months, at which they consulted a health care provider was 3 months, and at which they formally started antenatal care in a public facility was 4 months. The first health care provider consulted was a government clinic in 74% of women, a private medical practitioner in 24%, and a government hospital in 2%. Table 1 shows how the women discovered they were pregnant. One hundred and thirty women (41%) said they had been turned away from antenatal clinic when they tried to book. The reasons they were given are shown in Table 2.

The median number of months it took from finding out they were pregnant to completing the antenatal first visit was 2 (Figure 1). This delay had three components: 1) seeing a health provider after finding out they were pregnant (Figure 2); 2) attempting to book for antenatal care after seeing the health provider (Figure 3); and 3) actually starting antenatal care after attempting to do so (Figure 4). Of note was that taking 2 or more months to book after finding out about the pregnancy was associated with home pregnancy testing (62/93; 67%), as opposed to clinic pregnancy testing (44/106; 41%) (P<0.01).

Table 1 How pregnant women found out that they were pregnant (n=319)

Clinic pregnancy test	106 (33%)
Home pregnancy test	105 (33%)
Knew without testing	59 (19%)
Private practitioner pregnancy test	22 (7%)
Private practitioner ultrasound	21 (7%)
Other	6 (2%)

Table 2 Reasons women gave for being turned away when trying to book (n=317)

Clinic pregnancy test	106 (33%)
Home pregnancy test	105 (33%)
Knew without testing	59 (19%)
Private practitioner pregnancy test	22 (7%)
Private practitioner ultrasound	21 (7%)
Other	6 (2%)

Figure 1 Percentage of women starting antenatal care (y-axis) by number of months (x-axis) after finding out they were pregnant

Figure 2 Percentage of women going to a health care provider for the first time in the pregnancy (y-axis) by number of months (x-axis) after finding out they were pregnant

Figure 3 Percentage of women attempting to book for antenatal care (y-axis) by number of months (x-axis) after going to a health care provider for the first time
nt

Figure 4 Percentage of women actually receiving first-visit antenatal care (y-axis) by the number of months (x-axis) after attempting to book for antenatal care
Discussion

Municipal clinics are under-resourced for antenatal care and appear unable to provide a daily antenatal booking service. The greatest delays in booking for antenatal care appear to be from finding out about the pregnancy to seeing a health care provider (associated with home pregnancy confirmation), and from seeing a provider to making contact with the antenatal care system. These two delays involve the woman/community and the primary care system respectively. Innovations are needed to streamline the passage of women from pregnancy confirmation to starting antenatal care. One such innovation may be to provide pregnancy test kits to community health workers in the ward-based outreach teams.

COMPARISON OF GESTATIONAL AGE (GA) CALCULATED USING LAST NORMAL MENSTRUAL PERIOD (LNMP) VS ULTRASOUND IN WOMEN REQUESTING SECOND TOP AT CHRIS HANI BARAGWANATH ACADEMIC HOSPITAL (CHBAH)
DR BALOYI STEPHEN- University of the Witwatersrand
Background and introduction

GA presents a platform for prenatal testing, preterm labour management, and timing of post-date induction of labour, technique of TOP, reduces IOL for post-date pregnancies and significantly reduces the total workload. Methods for calculating gestational age include Naegeles rule, pregnancy wheel - LNMP and ultrasound. In busy units, booking scans are not possible for all patients but are recommended for selected patients. Ultrasound GA calculation helps in determining whether TOP can be performed in a hospital or as an outpatient basis. Higher GA terminations are performed in the hospital in order to avoid or minimize the risk of haemorrhage. In South Africa, Obstetric haemorrhage is among the highest causes of maternal dearth (2012)

Aims and Objectives

To compare GA calculated using LNMP VS Ultrasound in women requesting second trimester abortion at CHBAH

Methods

Study setting-CHBAH in Soweto with a population size 640588 which makes 50.38% of the adult population

Study population-Women who were referred for second trimester abortion were recruited (>18years)

Exclusion criteria- Women above 20weeks gestation, those who had TOP due to medical conditions like Pre enclampsia and those who did not give consent

Study design and sampling

Main study: A prospective cohort study where women were recruited for 3 days a week. Procedures done includes history, examination and Ultrasound

Data collection

Data was collected from medical files and through interviews. Data was entered into Microsoft excel spread sheet and exported into STATA10 statistical tool for analysis

Ethics

Study was approved by HREC of the University of the Witwatersrand. Hospital permission was granted by the CHBAH medical advisory committee on behalf of the CEO. All participants provided written informed consent

Results

The number of women interviewed during the study period was 211. The mean age was 26.52(SD±6.38) and the range of 18-43. The median parity of women was 1 with the IQR 1-2 and the range of 0-6. Two hundred and five women (97.16%) had primary and secondary school education. Hundred and three women were using contraception at the time of conception. Hundred and eight did not. Fifty one (24.17%) women were found to be HIV positive and HIV status of 14(6.64%) women was unknown. The median CD4cell count was 500(IQR=350-560). The range was 45-913. Twenty three women (48.94%) of those who were HIV positive used antiretroviral therapy (ART)

Table 1 Results



Fig 1 A Box and Whisker plot
Discussion

The Box and Whisker plot comparing GA calculated by two methods shows that the median was statistically significantly different and that there were more outliers when GA was calculated using dates and these could have surely have affected clinical management. The spearman rho was 0.38( p-0.00). There was no correlation between assessment of GA by dates and by sonar.

A study compared 2 Ultrasound protocols;

Group A- where routine early Ultrasound scans at 18-23 plus selective clinical indications were done.

And group B- where booking scans for all patients regardless of GA plus follow-ups for selective clinical indications were done.

Approximately 34% of patients benefited from the booking scans- there were reduced numbers of post dates pregnancies but at the same time increased the work loud significantly

A limitation of the study is that it may not be generalized to other regions of Gauteng and other provinces across SA. This population of women may be different from women who are planning pregnancy who may remember their dates
Conclusion

Gaby sonar is the most reliable way to effectively determine the GA early in pregnancy and should be offered to all women.

DOES THE AVAILABILITY OF A MOBILE-CONNECTED UMBILICAL DOPPLER DEVICE (UMBIFLOW™) IN A PRIMARY CARE MATERNITY SETTING REDUCE REFERRALS TO SPECIALISED CARE?
J Mufenda Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, South Africa

GS Gebhardt. Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, South Africa.

R van Rooyen. mHealth Inc.

G Theron. Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, South Africa.

Umbiflow™ is a mobile-connected Doppler device that utilises continuous waveform to detect blood flow within the umbilical cord and is used to ascertain placental function. It consists of a handheld proprietary vascular transducer (probe) with a universal serial bus (USB) cable that connects to any windows-based computer; where the necessary software is installed. An integrated 3G card facilitates a mobile internet connection and automatic upload of exam results to a central server for remote expert support and electronic health record management. Umbiflow is inexpensive and specifically designed for use by midwives and nurses and a robust solution for rural settings. The system is easy-to-use and operators can be trained within just a few days.
The value of Doppler in detecting intra-uterine growth restriction when there is poor fetal growth was already established in prior studies and Doppler testing of the umbilical artery for suspected intra-uterine growth restriction is currently part of the routine ultrasound protocol of the Western Cape. These Dopplers are performed on ultrasound machines at more specialised referral hospitals. The main aim of this field study was to determine whether the use of Umbiflow™ for umbilical artery Doppler in patients with a suspected decreased symphysis fundal (SF) growth could safely lead to a decreased number of patients requiring referral to a more specialised level of care. As many patients book late with an uncertain gestation and thus uncertainty as to the SF measurement, a secondary aim of the study was to evaluate the effectiveness of Doppler as a screening tool for concealed intra-uterine growth restriction in late bookers by using a single screening cut-off value that will be abnormal for any gestation >28 weeks.
The study was conducted at two sub-metropolitan antenatal facilities, namely Kraaifontein Midwife Obstetric Unit and Durbanville Clinic, within the Tygerberg Hospital drainage. All patients with a decreased SF measurement underwent testing on site; performed by the midwife directly after the clinical examination. Midwifes were first trained theoretically for 2 days followed by a 1-2 weeks hands-on training in the use of Doppler on-site at the beginning of the study. Patients with normal Doppler for their respective gestation (defined as a Resistance Index (RI) of <75^th centile) were re-assured and followed up as per routine. Patients with Doppler RI values between the 75^th and 95^th percentile for their specific gestation were referred to the doctor’s clinic at a district hospital on the next working day. Patients with clearly abnormal (>95^th centile) values were referred to the regional hospital (Tygerberg) high risk clinic or labour ward on the same day.
Patients that booked late (clinically >28 weeks by SF) received a screening Doppler test in addition to routine management. A RI value of 0.8 or more was used as a cut-off to refer for specialist evaluation, as it will be >95^th centile for any gestation after 28 weeks. Those with value below were managed as any other late booker.
Dopplers could be conducted effectively by nurses who had not used this technique or software before but had received short but adequate training. During the first 5 months of the field trial, 133 women underwent Doppler testing; 33 for decreased SF and 100 screening for late booking. So far, 23 of the women with poor SF and 41 of those with a screening Doppler have delivered and data is presented on them. The demographic characteristics of each group were similar and indicate low risk patients as shown in the table below:

Of the 23 with decreased SF, 22 had booked early enough to undergo routine ultrasound dating to ensure accurate gestational age calculation. Ten (43.4%) had a normal Doppler and could be reassured without the need for referral. All of them had a good post-natal outcome with a mean birth weight of 2781 gram and 5-minute Apgar of 9. Five patients had clearly abnormal Dopplers (RI >95^th centile) and were referred for further management; one had severe intra-uterine growth restriction (subsequent fetal growth <1^st centile); 2 had fetal compromise necessitating Caesarean section and a further patient developed complications of hypertension.

Of the late bookers, 3 women (7.3%; who were otherwise completely healthy and low-risk) were referred for abnormal values; all three remained at referral level and eventually had complicated pregnancies. The remaining 38 (normal Doppler) had uncomplicated pregnancies and deliveries. Twenty-five percent of women referred to a referral hospital for Doppler did not attend their appointment. Because of its mobile-connectivity, all results (including monitoring of the entire field trial, e.g. the exact time the nurse spent on the procedure) could be assessed and evaluated remotely. No patient with a normal Doppler had a poor outcome.

AN ACCURATE SEMI-AUTOMATED OSCILLOMETRIC BLOOD PRESSURE DEVICE FOR USE IN PREGNANCY (INCLUDING PRE-ECLAMPSIA) IN A LOW- AND MIDDLE-INCOME COUNTRY POPULATION: THE MICROLIFE 3AS1-2
H Nathan
Abstract

Objectives – To assess the accuracy of the Microlife 3AS1-2 blood pressure (BP) device in pregnancy and pre-eclampsia. in a low-resource setting.

Methods – Prospective validation according to the British Hypertension Society (BHS) protocol. 45 pregnant women were recruited from Kimberley Hospital (South Africa), of whom 15 had pre-eclampsia. Each participants had nine sequential same-arm measurements taken, alternating between mercury sphygmomanometery and the device.

Results - The Microlife 3AS1-2 device achieved an overall B/A grade in pregnancy (including pre-eclampsia), passing all the BHS protocol requirements and achieving the International Organization for Standardization standard with a mean difference and standard deviation of -3.8±7.3mmHg and -1.5±6.2mmHg for systolic and diastolic pressures respectively.

Conclusion - The Microlife 3AS1-2 device can be recommended for use in pregnancy, including pre-eclampsia. In addition, it fulfills the requirements stipulated by the World Health Organisation for an automated BP device suitable for use in a low-resource setting. This makes it the ideal device for use in antenatal clinics and primary health-care facilities in low- and middle-income countries.
Introduction

Hypertension in pregnancy complicates up to 10% of pregnancies [1]. Globally, pre-eclampsia is the second-leading cause of maternal mortality, resulting in an estimated 72,000 maternal deaths annually, 99% of which occur in low- and middle-income countries (LMICs). The World Health Organisation (WHO) estimates pre-eclampsia contributes to 500,000 perinatal deaths annually [2].

Accurate blood pressure (BP) measurement in pregnancy is essential for early identification and management of pre-eclampsia. Whilst mercury sphygmomanometry is the ‘gold standard’, it is subject to inaccuracies including misinterpretation of Korotkoff sounds and observer bias, and requires specific training and skill. In many LMICs, healthcare providers may have limited access to training in the conventional technique, and primary care relies increasingly on a cadre of ‘community health workers’ who have no formal medical training. Thus, use of automated devices is a more attractive option for many healthcare settings.

It is recommended that BP measurement devices be validated before introduction into clinical practice, to confirm their accuracy. Whilst more than 400 automated devices have been introduced commercially over the past 25 years, many have not been validated according to internationally recognised protocols. Far fewer have been validated for use in pregnancy and particularly in pre-eclampsia, where studies have shown that the underestimation of BP leads to clinically significant errors and under-detection of the disease [3]. In keeping with recommendations of the British Hypertension Society (BHS) protocol [4], the International Organization for Standardization (ISO) now recommends that devices intended for use in pregnancy should be separately validated [5].

Once validated, devices may still be unsuitable for use in a LMIC setting if they are expensive, fragile, have large power requirements and need to be frequently calibrated. Our group has previously validated the Microlife 3AS1-2, a hand-held, upper-arm, semi-automated oscillometric BP device, suitable for use in LMICs, in an adult non-pregnant population [6]. In this study, we describe the validation of the device in pregnancy and pre-eclampsia.
Methods

Women were recruited from the antenatal ward and clinics at Kimberley Hospital Complex (Kimberley, South Africa). Written informed consent was obtained and subjects fulfilled the BHS protocol requirements in pregnancy. Fifteen additional pre-eclamptic women were recruited, as recommended by ISO. At least ten women were in their second trimester, ten in their third trimester and twelve women had an arm circumference greater than 35cm. Women were excluded from the study if after three attempts the device failed to produce an oscillometric reading, if the participant had any arrhythmia or if the Korotfoff sounds were too weak to be accurately interpreted.

Three observers, experienced in the performance of validation studies, took nine sequential same-arm BP measurements for each subject using a double-headed teaching stethoscope and alternating between two calibrated mercury sphygmomanometers and the Microlife 3AS1-2. Korotkoff V was used to identify diastolic BP. The observers were blinded to each other’s auscultatory readings and to the device readings.
Data were then analysed according to the BHS protocol guidelines. Device readings were alternately compared to each of the observers’ readings “before” (difference backward) and “after” (difference forward) for systolic and diastolic BPs respectively, resulting in six calculable differences. The set of differences with the lowest absolute values for each subject was selected as the ‘best difference’.
Results

A total of 47 pregnant women were recruited. The first 30 women to fulfill the BHS protocol criteria were selected for analysis, with a subsequent analysis also including 15 pre-eclamptic women. Two women were excluded to fulfill the distribution/BP range criteria. Mean demographic values were: Age - 30 years; Weight - 81kg; Arm circumference - 31cm; Gestation – 30 weeks; Systolic BP – 138mmHg; Diastolic BP 87 mmHg.

The Microlife 3AS1-2 achieved an overall B/A grade (n=45), with an A/A grade in pregnancy alone (n=30). The device also achieved the ISO standard for mean difference ± standard deviation (≤ 5 ± 8 mmHg) in pregnancy, including pre-eclampsia (Table 1).
Discussion

The Microlife 3AS1-2 is a semi-automated BP device that can be recommended for use in pregnancy, including pre-eclampsia, according to the BHS protocol. To our knowledge it is the first device to be validated as accurate in pregnancy and to fulfill the WHO requirements for use in low-resource settings. It has low power requirements (due to the manual inflation feature), a large and easily legible LCD display, and can function at extremes of temperatures and high humidity. Its dual function as an auscultatory and oscillometric device allows for accurate use by staff with minimal training while its durability, long battery life and minimal calibration requirements ensure longevity of use. Costing less than 20 Euros, it is comparatively cheap compared to others on the market.

Impaired accuracy of some automated devices at higher BPs, particularly in pre-eclamptic women, may be due to the pathophysiological changes of the disease, including decreased arterial compliance and increased interstitial oedema; these are thought to alter the transmission of the oscillometric waveform, thereby underestimating the true BP. The Microlife 3AS1-2, however achieves the BHS and ISO protocols standard for use in pre-eclampsia, and therefore can be recommended for use in this high-risk group.
In a high-income setting, most pre-eclamptic women are diagnosed early, through regular antenatal monitoring, allowing them to be managed in an appropriate and timely manner. However, in LMICs, pre-eclampsia is often detected at a late stage due to infrequent antenatal attendance and inaccurate BP monitoring. Research has repeatedly linked adverse outcome to the late detection of hypertensive disorders of pregnancy [7]. The Microlife 3AS1-2 is an ideal device for use in LMICs; further design adaptations currently underway include a traffic light warning system to indicate extremes of BP, and a re-chargeability function.
Conclusion

The Microlife 3AS1-2 device can be recommended for use in pregnancy, including pre-eclampsia, according to BHS protocol. It also fulfils the WHO requirements for an automated device suitable for use in a low-resource setting.

References

1. Duley, L. The global impact of pre-eclampsia and eclampsia. in Seminars in perinatology. 2009. Elsevier.

2. Hutcheon, J.A., S. Lisonkova, and K. Joseph, Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy. Best Practice & Research Clinical Obstetrics & Gynaecology, 2011. 25(4): p. 391-403.

3. Gupta, M., et al., Accuracy of oscillometric blood pressure monitoring in pregnancy and pre‐eclampsia. BJOG: An International Journal of Obstetrics & Gynaecology, 1997. 104(3): p. 350-355.

4. O’Brien, E., et al., The British Hypertension Society protocol for the evaluation of blood pressure measuring devices. J hypertens, 1993. 11(Suppl 2): p. S43-S62.

5. ISO, -. International Standard. Non-invasive sphygmomanometers. Part 2: Clinical investigation of automated measurement type. 2013.

6. de Greeff, A., et al., Development of an accurate oscillometric blood pressure device for low resource settings. Blood pressure monitoring, 2008. 13(6): p. 342-348.

7. McCaw-Binns, A., et al., Strategies to prevent eclampsia in a developing country: I. Reorganization of maternity services. International Journal of Gynecology & Obstetrics, 2004. 87(3): p. 286-294.

Table 1. Results according to the BHS protocol

	Grade	≤5 mmHg	≤10 mmHg	≤15 mmHg	Mean difference ± SD (mmHg)
Pregnancy (n=30) Systolic BP Diastolic BP	A A	63 81	86 93	96 99	-2.9 ± 7.4 0.3 ± 5.0
Pregnancy (including pre-eclampsia) (n=45) Systolic BP Diastolic BP	B A	58 70	82 90	95 97	-3.8 ± 7.3 -1.5 ± 6.2

SD – standard deviation
Figure 1 Mean against difference plot for systolic pressure in pregnancy and pre-eclampsia (n=45)



Figure 2. Mean against difference plot for diastolic pressure in pregnancy and pre-eclampsia (n=45)



MICROCIRCULATION IN WOMEN WITH SEVERE PRE-ECLAMPSIA AND HELLP SYNDROME
Jérôme Cornette, Emilie Herzog, Erik AB Buijs^, ,Johannes J Duvekot, Dimitris,Rizopoulos, Wim CJ Hop, Dick Tibboel, Eric AP Steegers

Erasmus MC, Rotterdam , The Netherlands