Browsing by Author "Hall, David R."
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- ItemAre women with history of pre-eclampsia starting a new pregnancy in good nutritional status in South Africa and Zimbabwe?(BioMed Central, 2018-06-15) Cormick, Gabriela; Betran, Ana Pilar; Harbron, Janetta; Dannemann Purnat, Tina; Parker, Catherine; Hall, David R.; Seuc, Armando H.; Roberts, James M.; Belizan, Jose M.; Hofmeyr, G. JustusBackground: Maternal nutritional status before and during pregnancy is an important contributor to pregnancy outcomes and early child health. The aim of this study was to describe the preconceptional nutritional status and dietary intake during pregnancy in high-risk women from South Africa and Zimbabwe. Methods: This is a prospective observational study, nested to the CAP trial. Anthropometric measurements before and during pregnancy and dietary intake using 24-h recall during pregnancy were assessed. The Intake Distribution Estimation software (PC-SIDE) was used to evaluate nutrient intake adequacy taking the Estimated Average Requirement (EAR) as a cut-off point. Results: Three hundred twelve women who had pre-eclampsia in their last pregnancy and delivered in hospitals from South Africa and Zimbabwe were assessed. 73.7 and 60.2% women in South Africa and Zimbabwe, respectively started their pregnancy with BMI above normal (BMI ≥ 25) whereas the prevalence of underweight was virtually non-existent. The majority of women had inadequate intakes of micronutrients. Considering food and beverage intake only, none of the micronutrients measured achieved the estimated average requirement. Around 60% of pregnant women reported taking folic acid or iron supplements in South Africa, but almost none did so in Zimbabwe. Conclusion: We found a high prevalence of overweight and obesity and high micronutrient intake inadequacy in pregnant women who had the previous pregnancy complicated with pre-eclampsia. The obesity figures and micronutrient inadequacy are issues of concern that need to be addressed. Pregnant women have regular contacts with the health system; these opportunities could be used to improve diet and nutrition.
- ItemAn audit of stillborn babies in mothers with diabetes mellitus at a tertiary South African Hospital(Taylor & Francis, 2019-12) Hall, David R.; Masona, Deidre; Gebhardta, Gabriel; Rossouw, Jana Nicolene; Obstetrics & GynaecologyObjectives and design: This study is a retrospective audit spanning six years following the implementation of a new guideline on the management of diabetes in pregnancy. It aims to describe the patient profile of pregnancies complicated by diabetes and stillbirth. Setting: The study was performed in Tygerberg Hospital, Cape Town, a secondary and tertiary referral centre. Subjects: Fifty-eight pregnancies were complicated by stillbirth (> 500 g). Outcome measures: the patient profile, gestational age, co-morbidities, foetal/placental monitoring and avoidable factors were described. Results: Many patients (32%) booked after 24 weeks’ gestation and missed appointments were common (26.2%). Stillbirths ascribed to diabetes constituted 2.3% of all stillbirths at the hospital during the study period. Of the stillbirths 28.1% had Type I diabetes mellitus (DM), 64.9% had Type II and 7.0% were in patients with gestational diabetes. The median HbA1c at delivery was 8.4% (range 6.0–14.1%). In the Type II group, 31 (77.5%) of the stillbirths occurred after 36 weeks, while those among the Type I cases ranged from 26 to 38 weeks. Conclusion: Stillbirths amongst pregnant women with diabetes constituted a small percentage of the total stillbirth burden. Emphasising the importance of appropriate antenatal care to women with diabetes and increased surveillance from 36 weeks’ gestation may lower the number of stillbirths.
- ItemThe CRADLE vital signs alert : qualitative evaluation of a novel device designed for use in pregnancy by healthcare workers in low-resource settings(BioMed Central, 2018-01-05) Nathan, Hannah L.; Boene, Helena; Munguambe, Khatia; Sevene, Esperanca; Akeju, David; Adetoro, Olalekan O.; Charanthimath, Umesh; Bellad, Mrutyunjaya B.; De Greeff, Annemarie; Anthony, John; Hall, David R.; Steyn, Wilhelm; Vidler, Marianne; Von Dadelszen, Peter; Chappell, Lucy C.; Sandall, Jane; Shennan, Andrew H.Background: Vital signs measurement can identify pregnant and postpartum women who require urgent treatment or referral. In low-resource settings, healthcare workers have limited access to accurate vital signs measuring devices suitable for their environment and training. The CRADLE Vital Signs Alert (VSA) is a novel device measuring blood pressure and pulse that is accurate in pregnancy and designed for low-resource settings. Its traffic light early warning system alerts healthcare workers to the need for escalation of care for women with hypertension, haemorrhage or sepsis. This study evaluated the usability and acceptability of the CRADLE VSA device. Methods: Evaluation was conducted in community and primary care settings in India, Mozambique and Nigeria and tertiary hospitals in South Africa. Purposeful sampling was used to convene 155 interviews and six focus groups with healthcare workers using the device (n = 205) and pregnant women and their family members (n = 41). Interviews and focus groups were conducted in the local language and audio-recorded, transcribed and translated into English for analysis. Thematic analysis was undertaken using an a priori thematic framework, as well as an inductive approach. Results: Most healthcare workers perceived the CRADLE device to be easy to use and accurate. The traffic lights early warning system was unanimously reported positively, giving healthcare workers confidence with decision-making and a sense of professionalism. However, a minority in South Africa described manual inflation as tiring, particularly when measuring vital signs in obese and hypertensive women (n = 4) and a few South African healthcare workers distrusted the device’s accuracy (n = 7). Unanimously, pregnant women liked the CRADLE device. The traffic light early warning system gave women and their families a better understanding of the importance of vital signs in pregnancy and during the postpartum period. Conclusion: The CRADLE device was well accepted by healthcare workers from a range of countries and levels of facility, including those with no previous vital signs measurement experience. The device motivated women to attend primary care and encouraged them to accept treatment and referral.
- ItemDouble blind, randomised, placebocontrolled trial to evaluate the efficacy of esomeprazole to treat early onset pre-eclampsia (PIE Trial) : a study protocol(BMJ Publishing Group, 2015) Cluver, Catherine Anne; Walker, Susan P.; Mol, Ben W.; Theron, Gerard B.; Hall, David R.; Hiscock, Richard; Hannan, N.; Tong, S.Introduction: Pre-eclampsia is a major complication of pregnancy, globally responsible for 60 000 maternal deaths per year, and far greater numbers of fetal losses. There is no definitive treatment other than delivery. A drug that can quench the disease process could be useful to treat early onset pre-eclampsia, as it could allow pregnancies to safely continue to a gestation where fetal outcomes are significantly improved. We have generated preclinical data to show esomeprazole, a proton pump inhibitor used for gastric reflux, has potent biological effects that makes it a worthwhile therapeutic candidate. Esomeprazole potently decreases soluble fms-like tyrosine kinase 1 (sFlt-1) and soluble endoglin secretion from placenta and endothelial cells, and has biological actions to mitigate endothelial dysfunction and oxidative stress. Methods and analysis: We propose undertaking a phase II, double blind, randomised controlled clinical trial to examine whether administering 40 mg esomeprazole daily may prolong gestation in women with early onset pre-eclampsia. We will recruit 120 women (gestational age of 26+0 to 31+6 weeks) who will be randomised to receive either esomeprazole or an identical placebo. The primary outcome will be the number of days from randomisation to delivery. Secondary outcomes include maternal, fetal and neonatal composite and individual outcomes. Maternal outcomes include maternal death, eclampsia, pulmonary oedema, severe renal impairment, cerebral vascular events and liver haematoma or rupture. Neonatal outcomes include neonatal death within 6 weeks after the due date, intraventricular haemorrhage, necrotising enterocolitis and bronchopulmonary dysplasia. We will examine whether esomeprazole can decrease serum sFlt-1 and soluble endoglin levels and we will record the safety of esomeprazole in these pregnancies. Ethics and dissemination: This study has ethical approval (Protocol V.2.4, M14/09/038, Federal Wide assurance Number 00001372, IRB0005239), and is registered with NHREC (ID 3649) and the Pan African Clinical Trial Registry (PACTR201504000771349). Data will be presented at international conferences and published in peer-reviewed journals.
- ItemEthical issues in pre-eclampsia : hurry up and wait(2014-12) Hall, David R.; Van Niekerk, Anton A.; Stellenbosch University. Faculty of Arts and Social Sciences. Dept. of Philosophy.ENGLISH ABSTRACT: Pre-eclampsia is a common and dangerous condition of pregnancy. During clinical care the sensitive obstetrician will frequently recognise moral ambiguity and ethical conflicts. It is important to understand the pertinent issues and find ways of resolving them. Counselling is an important element of modern medicine. In deciding which counselling model to apply, clinicians must consider many variables including the particular clinical scenario, strength of evidence, and the justifiable limits of paternalism and autonomy in a position of shared responsibility. Couples have a moral right to procreate even when the pursuit of pregnancy involves significant risks. However, with their understanding of care ethics as well as rights ethics, informed women are well placed to negotiate the extremes of these positions when deciding whether to risk a pregnancy or not. The concept of the “fetal patient” is a helpful one. An autonomous woman may choose to confer or deny this status to her previable fetus, while obstetricians must balance autonomy- and beneficence-based obligations to the pregnant woman with beneficence-based obligations to her fetus. Maternal behaviour that harms the fetus and future child is categorised as maternal-fetal conflict. However, any pregnant woman is morally required to avoid harming the fetus, if this can be done without sacrificing her own important interests. The term non-compliance implies a hierarchical nature in the doctor-patient relationship. This reduces patient agency, erodes trust and conflicts with informed choice. Although sometimes justified, this “label” generally does more harm than good. Expectant management of early pre-eclampsia recognises that neonatal intensive care is an expensive and limited resource. The ultimate goal of expectant management remains the safety of the mother and the delivery of a live infant who will not require intensive and prolonged neonatal care. This judicious use of neonatal intensive care improves distributive justice but by consenting to expectant management as an inpatient, the pregnant woman voluntarily restricts her freedom. The decision is morally undergirded by the value accorded to the viable fetus and the scientific evidence informing the decision. When an extremely preterm, growth restricted fetus requires delivery, resuscitation may become an issue for consideration. The distinction between withholding resuscitation in such cases, or initiating but later withdrawing care is morally irrelevant. Categories of optional and obligatory treatments are more helpful, but perinatologists must determine treatment thresholds through understanding the relevant data and ethics issues. Finally, women do not lose their rights when they become terminally ill. When an undelivered woman is declared brain dead following complications of pre-eclampsia, her doctors and family must formulate clear plans for her and her living fetus. She must still be treated with respect and her right to die with dignity not forgotten. Extension of somatic support to optimise the outcome of her fetus can be supported ethically provided that the fetus is at the threshold of viability, the support is not prolonged (distributive justice), advanced level support is available with a successful outcome likely, and that doctors and family are in clear agreement.
- ItemExpectant management of early onset, severe pre-eclampsia(Stellenbosch : Stellenbosch University, 1999) Hall, David R.; Stellenbosch University. Faculty of . Dept. of .
- ItemFactors affecting the propensity of tsetse flies to enter houses and attack humans inside : increased risk of sleeping sickness in warmer climates(PLoS, 2013-04) Vale, Glyn A.; Hargrove, John W.; Chamisa, Andrew; Hall, David R.; Mangwiro, Clement; Torr, Stephen J.Background: Sleeping sickness, or human African trypanosomiasis, is caused by two species of Trypanosoma brucei that are transmitted to humans by tsetse flies (Glossina spp.) when these insects take a bloodmeal. It is commonly assumed that humans must enter the normal woodland habitat of the flies to become infected, but recent studies found that tsetse frequently attack humans inside buildings. Factors affecting human/tsetse contact in buildings need identification. Methodology/Principal Findings: In Zimbabwe, tsetse were allowed access to a house via an open door. Those in the house at sunset, and those alighting on humans in the house during the day, were caught using hand-nets. Total catches were unaffected by: (i) the presence of humans in the house and at the door, (ii) wood smoke from a fire inside the house or just outside, (iii) open windows, and (iv) chemicals simulating the odor of cattle or of humans. Catches increased about 10-fold with rising ambient temperatures, and during the hottest months the proportion of the total catch that was taken from the humans increased from 5% to 13%. Of the tsetse caught from humans, 62% consisted of female G. morsitans morstans and both sexes of G. pallidipes, i.e., the group of tsetse that normally alight little on humans. Some of the tsetse caught were old enough to be effective vectors. Conclusion/Significance: Present results confirm previous suggestions that buildings provide a distinctive and important venue for transmission of sleeping sickness, especially since the normal repellence of humans and smoke seems poorly effective in such places. The importance of the venue would be increased in warmer climates.
- ItemInter-pregnancy interval and risk of recurrent pre-eclampsia : systematic review and meta-analysis(BioMed Central, 2016-07-18) Cormick, Gabriela; Betrán, Ana Pilar; Ciapponi, Agustín; Hall, David R.; Hofmeyr, G. JustusBackground: Women with a history of pre-eclampsia have a higher risk of developing pre-eclampsia in subsequent pregnancies. However, the role of the inter-pregnancy interval on this association is unclear. Objective: To explore the effect of inter-pregnancy interval on the risk of recurrent pre-eclampsia or eclampia. Search strategy: MEDLINE, EMBASE and LILACS were searched (inception to July 2015). Selection criteria: Cohort studies assessing the risk of recurrent pre-eclampsia in the immediate subsequent pregnancy according to different birth intervals. Data collection and analysis: Two reviewers independently performed screening, data extraction, methodological and quality assessment. Meta-analysis of adjusted odds ratios (aOR) with 95 % confidence intervals (CI) was used to measure the association between various interval lengths and recurrent pre-eclampsia or eclampsia. Main results: We identified 1769 articles and finally included four studies with a total of 77,561 women. The meta-analysis of two studies showed that compared to inter-pregnancy intervals of 2–4 years, the aOR for recurrent pre-eclampsia was 1. 01 [95 % CI 0.95 to 1.07, I2 0 %] with intervals of less than 2 years and 1.10 [95 % CI 1.02 to 1.19, I2 0 %] with intervals longer than 4 years. Conclusion: Compared to inter-pregnancy intervals of 2 to 4 years, shorter intervals are not associated with an increased risk of recurrent pre-eclampsia but longer intervals appear to increase the risk. The results of this review should be interpreted with caution as included studies are observational and thus subject to possible confounding factors.
- ItemMaternal and perinatal adverse outcomes in women with pre-eclampsia cared for at facility-level in South Africa : a prospective cohort study(Edinburgh University Global Health Society, 2018) Nathan, Hannah L.; Seed, Paul T.; Hezelgrave, Natasha L.; De Greeff, Annemarie; Lawley, Elodie; Conti-Ramsden, Frances; Anthony, John; Steyn, Wilhelm; Hall, David R.; Chappell, Lucy C.; Shennan, Andrew H.Background: Hypertensive disorders of pregnancy contribute to 14% of all maternal deaths, the majority of which occur in low- and middle-income countries. The aim of the study was to describe the maternal and perinatal clinical outcomes of women with pre-eclampsia living in middle- and low-income countries. Methods The study was a prospective observational study of women with pre-eclampsia (n = 1547, 42 twin pregnancies) at three South African tertiary facilities. Using stepwise logistic regression model area under the receiver operating characteristic curve (AUROC) values, the association between maternal baseline and admission characteristics and risk of adverse outcomes was evaluated. Main outcome measures were eclampsia, kidney injury and perinatal death. Results In 1547 women with pre-eclampsia, 16 (1%) died, 147 (9.5%) had eclampsia, four (0.3%) had a stroke and 272 (17.6%) had kidney injury. Of the 1589 births, there were 332 (21.0%) perinatal deaths; of these, 281 (84.5%) were stillbirths. Of 1308 live births, 913 (70.0%) delivered <37 completed weeks and 544 (41.7%) delivered <34 weeks’ gestation. Young maternal age (AUROC = 0.76, 95% confidence interval (CI) = 0.71- 0.80) and low Body Mass Index BMI (AUROC 0.65, 95% CI = 0.59-0.69) were significant predictors of eclampsia. Highest systolic blood pressure had the strongest association with kidney injury, (AUROC = 0.64, 95% CI = 0.60-0.68). Early gestation at admission was most strongly associated with perinatal death (AUROC = 0.81, 95% CI = 0.77-0.84). Conclusions The incidence of pre-eclampsia complications, perinatal death and preterm delivery in women referred to tertiary care in South Africa was much higher than reported in other low- and middle-income studies and despite access to tertiary care interventions. Teenage mothers and those with low BMI were at highest risk of eclampsia. This information could be used to inform guidelines, the research agenda and policy.
- ItemNow, but not yet : tension in obstetrics(Stellenbosch : University of Stellenbosch, 2010-06-17) Hall, David R.Inaugural address delivered on 17 June 2010.
- ItemPregnancy outcomes in super-obese women – an even bigger problem? A prospective cohort study(Health & Medical Publishing Group, 2014-08) Nieuwoudt, Marina; Van der Merwe, Johannes Lodewicus; Harvey, Justin; Hall, David R.Objective. To investigate whether differences exist in adverse pregnancy outcomes between morbidly obese (body mass index (BMI, kg/m2) 40 - 49.9) and super-obese women (BMI ≥50). Methods. A prospective cohort study was undertaken at Tygerberg Hospital, a referral centre in the Western Cape Province of South Africa, of morbidly obese and super-obese pregnant women recruited from the antenatal clinic. Data were collected from the files 6 weeks after delivery. Primary outcomes included hypertension, diabetes mellitus and fetal macrosomia. Secondary outcomes included baseline characteristics, previous complications, antenatal and peripartum complications, and short-term neonatal outcomes. Results. Sixty-six morbidly obese and 46 super-obese women were enrolled. Super-obese women experienced significantly higher incidences of pre-eclampsia (24% v. 9%; p=0.03) and interuterine growth restriction (13% v. 2%; p=0.02) than morbidly obese women, and both groups had a high incidence of gestational diabetes (24% v. 24%; non-significant (NS)). Both super-obese and morbidly obese women experienced high rates of caesarean section (54% v. 41%; NS). In super-obese women these procedures lasted longer (50 v. 41 minutes; p<0.01) and there were more surgical complications (36% v. 7%; p=0.01). Prolonged admission (>3 days) after delivery was also more common in super-obese women (65% v. 42%; p=0.03). Conclusion. Super-obese women encounter more major pregnancy complications (especially hypertensive, pre-eclamptic and surgical) than morbidly obese women, emphasising the fact that these women should be managed at institutions with sufficient expertise.
- ItemPregnancy-related acute kidney injury in preeclampsia : risk factors and renal outcomes(American Heart Association, 2019) Conti-Ramsden, Frances I.; Nathan, Hannah L.; De Greeff, Annemarie; Hall, David R.; Seed, Paul T.; Chappell, Lucy C.; Shennan, Andrew H.; Bramham, K.ENGLISH ABSTRACT: Preeclampsia is a common cause of acute kidney injury (AKI) in low- and middle-income countries, but AKI incidence in preeclampsia, its risk factors, and renal outcomes are unknown. A prospective observational multicenter study of women admitted with preeclampsia in South Africa was conducted. Creatinine concentrations were extracted from national laboratory databases for women with maximum creatinine of ≥90 μmol/L (≥1.02 mg/dL). Renal injury and recovery were defined by Kidney Disease Improving Global Outcomes creatinine criteria. Predefined risk factors, maternal outcomes, and neonatal outcomes were compared between AKI stages. Of 1547 women admitted with preeclampsia 237 (15.3%) met AKI criteria: 6.9% (n=107) stage 1, 4.3% (n=67) stage 2, and 4.1% (n=63) stage 3. There was a higher risk of maternal death (n=7; relative risk, 4.3; 95% CI, 1.6–11.4) and stillbirth (n=80; relative risk, 2.2; 95% CI, 1.8–2.8) in women with AKI compared with those without. Perinatal mortality was also increased (89 of 240; 37.1%). Hypertension in a previous pregnancy was the strongest predictor of AKI stage 2 or 3 (odds ratio, 2.24; 95% CI, 1.21–4.17). Renal recovery rate reduced with increasing AKI stage. A third of surviving women (76 of 230 [33.0%]) had not recovered baseline renal function by discharge. Approximately half (39 of 76; 51.3%) of these women had no further creatinine testing post-discharge. In summary, AKI was common in women with preeclampsia and had high rates of associated maternal and perinatal mortality. Only two-thirds of women had confirmed renal recovery. History of a previous hypertensive pregnancy was an important risk factor.
- ItemReproductive autonomy : a case study(Health and Medical Publishing Group, 2016) Hall, David R.; Van Niekerk, Anton A.ENGLISH ABSTRACT: Reproductive autonomy (RA) has been challenged by the availability of genetic information, disability and the ethics of selective reproduction. Utilitarian and rights-based approaches, as well as procreative beneficence (PB) fail to provide compelling reasons for infringing RA, and may even be likened to dangerous eugenics. Parents are not morally obliged to prevent the birth of a disabled child. Society should rather adopt inclusivity, recognising and providing persons with disabilities opportunities for capability and worthwhile lives.
- ItemReproductive autonomy : a case study(Health & Medical Publishing Group, 2016-11) Hall, David R.; Van Niekerk, Anton A.Reproductive autonomy (RA) has been challenged by the availability of genetic information, disability and the ethics of selective reproduction. Utilitarian and rights-based approaches, as well as procreative beneficence (PB) fail to provide compelling reasons for infringing RA, and may even be likened to dangerous eugenics. Parents are not morally obliged to prevent the birth of a disabled child. Society should rather adopt inclusivity, recognising and providing persons with disabilities opportunities for capability and worthwhile lives.
- ItemA risk prediction model for the assessment and triage of women with hypertensive disorders of pregnancy in low-resourced settings : the miniPIERS (pre-eclampsia integrated estimate of risk) multi-country prospective cohort study(PLoS, 2014-01-21) Payne, Beth A.; Hutcheon, Jennifer A.; Ansermino, J. Mark; Hall, David R.; Bhutta, Zulfiqar A.; Bhutta, Shereen Z.; Biryabarema, Christine; Grobman, William A.; Groen, Henk; Haniff, Farizah; Li, Jing; Magee, Laura A.; Merialdi, Mario; Nakimuli, Annettee; Qu, Ziguang; Sikandar, Rozina; Sass, Nelson; Sawchuck, Diane; Steyn, D. Wilhelm; Widmer, Mariana; Zhou, Jian; Von Dadelszen, PeterBackground: Pre-eclampsia/eclampsia are leading causes of maternal mortality and morbidity, particularly in low- and middle- income countries (LMICs). We developed the miniPIERS risk prediction model to provide a simple, evidence-based tool to identify pregnant women in LMICs at increased risk of death or major hypertensive-related complications. Methods and Findings: From 1 July 2008 to 31 March 2012, in five LMICs, data were collected prospectively on 2,081 women with any hypertensive disorder of pregnancy admitted to a participating centre. Candidate predictors collected within 24 hours of admission were entered into a step-wise backward elimination logistic regression model to predict a composite adverse maternal outcome within 48 hours of admission. Model internal validation was accomplished by bootstrapping and external validation was completed using data from 1,300 women in the Pre-eclampsia Integrated Estimate of RiSk (fullPIERS) dataset. Predictive performance was assessed for calibration, discrimination, and stratification capacity. The final miniPIERS model included: parity (nulliparous versus multiparous); gestational age on admission; headache/visual disturbances; chest pain/dyspnoea; vaginal bleeding with abdominal pain; systolic blood pressure; and dipstick proteinuria. The miniPIERS model was well-calibrated and had an area under the receiver operating characteristic curve (AUC ROC) of 0.768 (95% CI 0.735–0.801) with an average optimism of 0.037. External validation AUC ROC was 0.713 (95% CI 0.658–0.768). A predicted probability ≥25% to define a positive test classified women with 85.5% accuracy. Limitations of this study include the composite outcome and the broad inclusion criteria of any hypertensive disorder of pregnancy. This broad approach was used to optimize model generalizability. Conclusions: The miniPIERS model shows reasonable ability to identify women at increased risk of adverse maternal outcomes associated with the hypertensive disorders of pregnancy. It could be used in LMICs to identify women who would benefit most from interventions such as magnesium sulphate, antihypertensives, or transportation to a higher level of care.
- ItemShock index thresholds to predict adverse outcomes in maternal hemorrhage and sepsis : a prospective cohort study(Wiley, 2019) Nathan, Hannah L.; Seed, Paul T.; Hezelgrave, Natasha L.; De Greeff, Annemarie; Lawley, Elodie; Anthony, John; Steyn, Wilhelm; Hall, David R.; Chappell, Lucy C.; Shennan, Andrew H.Introduction: Shock index (SI) is a predictor of hemodynamic compromise in obstetric patients. The SI threshold for action is not well understood. We aimed to evaluate SI thresholds as predictors of outcomes in obstetric patients. Material and methods: We undertook a prospective cohort study at three South African hospitals of women with postpartum hemorrhage (n = 283) or maternal sepsis (n = 126). The “first” and “worst” SI following diagnosis were recorded. SI was compared with conventional vital signs as predictors of outcomes. The performance of SI <.9, SI .9‐1.69 and SI ≥1.7 to predict outcomes (maternal death; Critical Care Unit admission; major procedure; hysterectomy) and hemorrhage‐specific outcomes (lowest hemoglobin <70 g/l; blood transfusion ≥4 IU) were evaluated. Results: “First” SI was one of two best performing vital signs for every outcome in postpartum hemorrhage and sepsis. In hemorrhage, risk of all outcomes increased with increasing “first” SI; for blood transfusion ≥4 IU odds ratio was 4.24 (95% confidence interval 1.25‐14.36) for SI ≥1.7 vs SI .9‐1.69. In sepsis, risk of all outcomes increased with increasing “worst” SI. Sensitivity, specificity, positive and negative predictive values of “first” SI <.9 vs SI ≥.9 for maternal death were 100.0%, 55.2%, 4.6% and 100.0%, respectively, in hemorrhage and 80.0%, 50.4%, 12.3% and 96.7%, respectively, in sepsis. Conclusions: The shock index was a consistent predictor of outcomes compared with conventional vital signs in postpartum hemorrhage and sepsis. SI <.9 performed well as a rule‐out test and SI .9‐1.69 and SI ≥1.7 indicated increased risk of all outcomes in both cohorts. These thresholds may alert to the need for urgent intervention and prevent maternal deaths.
- ItemTowards an early warning system for Rhodesian sleeping sickness in Savannah Areas : man-like traps for tsetse flies(Public Library of Science, 2012-12) Vale, Glyn A.; Hall, David R.; Chamisa, Andrew; Torr, Stephen J.Background: In the savannahs of East and Southern Africa, tsetse flies (Glossina spp.) transmit Trypanosoma brucei rhodesiense which causes Rhodesian sleeping sickness, the zoonotic form of human African trypanosomiasis. The flies feed mainly on wild and domestic animals and are usually repelled by humans. However, this innate aversion to humans can be undermined by environmental stresses on tsetse populations, so increasing disease risk. To monitor changes in risk, we need traps designed specifically to quantify the responsiveness of savannah tsetse to humans, but the traps currently available are designed to simulate other hosts. Methodology/Principal Findings: In Zimbabwe, two approaches were made towards developing a man-like trap for savannah tsetse: either modifying an ox-like trap or creating new designs. Tsetse catches from a standard ox-like trap used with and without artificial ox odor were reduced by two men standing nearby, by an average of 34% for Glossina morsitans morsitans and 56% for G. pallidipes, thus giving catches more like those made by hand-nets from men. Sampling by electrocuting devices suggested that the men stopped flies arriving near the trap and discouraged trap-entering responses. Most of human repellence was olfactory, as evidenced by the reduction in catches when the trap was used with the odor of hidden men. Geranyl acetone, known to occur in human odor, and dispensed at 0.2 mg/h, was about as repellent as human odor but not as powerfully repellent as wood smoke. New traps looking and smelling like men gave catches like those from men. Conclusion/Significance: Catches from the completely new man-like traps seem too small to give reliable indices of human repellence. Better indications would be provided by comparing the catches of an ox-like trap either with or without artificial human odor. The chemistry and practical applications of the repellence of human odor and smoke deserve further study.
- ItemTreatment of hypertension during pregnancy(South African Heart Association, 2014) Hall, David R.Hypertensive disorders of pregnancy are on the increase and remain important causes of maternal and perinatal morbidity and mortality. The different classes of hypertension carry different risks but severe hypertension in itself remains a medical emergency. Pre-eclampsia is a particularly dangerous condition that may progress rapidly. During pregnancy mild hypertension without end-organ disease does not require treatment until levels of 150/100mmHg are reached. Acute severe hypertension must be diagnosed and treated expeditiously. The choice of anti-hypertensive agents is limited in pregnancy and physicians should choose agents which are regarded as safe and which they feel comfortable in using. After acute management, oral maintenance therapy will be indicated in many cases, although delivery is regarded as the only defi nitive treatment for pregnancy specifi c conditions such as pre-eclampsia. Previous pre-eclampsia is associated with increased rates of cardiovascular and metabolic disease in later life. This should prompt subsequent lifestyle education and intervention.
- ItemWeight-related quality of life in obese, pregnant women in South Africa(Taylor & Francis, 2017-09-11) Tisane, Matshidiso Agnes; Hall, David R.; Van der Merwe, J. L.Objective: The global obesity pandemic includes pregnant women. Obesity may negatively impact quality of life (QOL). A validated, obesity-specific, QOL assessment tool was used to assess the impact of obesity on five specific domains. Methods: A prospective cohort study was performed at Tygerberg Academic Hospital in South Africa. Morbid obesity was defined as a body mass index (BMI) of 40–49.9 kg/m2 and super-obesity as BMI > 50 kg/m2, using the first recorded weight during the pregnancy. Pregnant women with a BMI ≥ 40 were approached in the high-risk antenatal clinic where written informed consent was taken before recruitment. Using the QOL tool they answered statements about their current experiences. Results: A total of 66 morbidly obese and 46 super-obese women were enrolled across an age range of 18–45 years. Physical function and self-esteem were the domains with the lowest QOL scores. When comparing morbid with super obesity, all scores were significantly lower in the latter group except for the domains of self-esteem and sexual life. Conclusion: Morbid and super-obesity occur across the full spectrum of the adult reproductive period. Physical function and self-esteem are most affected while QOL is linked to the degree of obesity.