3. Electronic Theses and Dissertations (ETDs) - All submissions
Permanent URI for this communityhttps://wiredspace.wits.ac.za/handle/10539/45
Browse
18 results
Search Results
Item Antenatal depression screening and perintal depression among women at Rahima Moosa Hospital(2018) Marsay, CarinaIn South Africa, 30-40% of women suffer from perinatal depression. This has devastating consequences for both mother and infant, as depressed mothers are at higher obstetric risk and have diminished capacity to care for the physical and emotional needs of their infants. Without adequate screening, approximately 75% of women with perinatal depression will remain undiagnosed and only 10% of these women will receive treatment. Studies conducted in low, middle and high income settings have shown that it is feasible and acceptable to incorporate mental health screening and depression assessment, with referral, into antenatal clinics. The study reported in this dissertation aimed to investigate whether women attending the antenatal clinic at Rahima Moosa Hospital would benefit from antenatal screening for perinatal depression. This would be achieved by determining whether antenatal screening for depression lead to reduced symptoms of depression. In addition, the study was designed to compare the specificity and sensitivity of the Whooley screening questions with the Edinburgh Postnatal Depression Scale (EPDS) in detecting major depression during pregnancy. Lastly, the study aimed to explore the lived experiences, and barriers to care, of women identified as suffering from perinatal depression who were referred for further management. A mixed-method, explanatory design, involving three phases, was used. In the first phase, data were collected using quantitative measures, including a standardised biographical interview, the EPDS, the Whooley screening questions and the Structured Clinical Interview of DSM5. During the second and third phases, quantitative measures were used again to identify changes from phase one. Data were also collected using qualitative indepth interviews to explain results in greater depth. Perinatal depression is a significant public health problem that needs to be addressed in order to improve maternal and child health. Only by listening to the needs of women experiencing perinatal depression can mental health care be improved within obstetric services. Welldesigned research studies which use an explanatory, transformative design can be used to guide effective screening programmes, improve treatment and inform national policy.Item Statins and other lipid-lowering therapy and pregnancy outcomes in homozygous familial hypercholesterolaemia – a retrospective review of 39 pregnancies.(2018) Botha, Theunis ChristoffelBACKGROUND: Pregnancy in homozygous familial hypercholesterolaemia (HoFH) females is associated with further elevation of already markedly elevated low density lipoprotein cholesterol (LDL-C) levels, particularly if lipid-lowering therapy is discontinued, placing the mother and fetus at increased cardiovascular risk. Lipoprotein apheresis (LA) is the current recommended treatment for pregnant HoFH patients. However, this is costly, time consuming, and is not available in many countries. Alternative treatment strategies to control hypercholesterolaemia during pregnancy in HoFH patients are necessary. The aim of this study was to assess pregnancy outcomes in a cohort of female HoFH patients, many of whom received statins with or without other lipid lowering therapy. METHODS: This study was a retrospective review of 39 pregnancies from a cohort of 20 genotypically confirmed female HoFH patients. Demographic, clinical, laboratory and treatment information, particularly the use of medication during pregnancy, was extracted from hospital files. Either patients themselves or a close, surviving family member were contacted directly to obtain informed consent for anonymized data collection and additional information. We compared birth weights of statin exposed and statin unexposed infants with the Mann Whitney U test and utilized a one tailed t-test to compare lipid levels, prior to, and following pregnancy. We considered p <0.05 significant RESULTS: No maternal cardiac complications or deaths occurred during the pregnancies or during the first year postpartum. Twenty-five pregnancies were exposed to lipid-lowering therapy, of which 18 were exposed to statin therapy, just prior to or during the pregnancy. Thirty-three (84%) pregnancies carried to term, 3 (8%) premature deliveries and 3 (8%) miscarriages were observed. Complications associated with pregnancy in these HoFH patients, did not differ from those reported during pregnancies of otherwise healthy woman. CONCLUSION: HoFH is a severe disease impacting significantly on life expectancy. However, for many females with HoFH, despite the high cardiovascular risk, pregnancy is not uncommon. In resource poor settings and when LA is not available, lipid lowering therapy, particularly statin therapy during pregnancy, appears to be safe for both mother and fetus and is an acceptable alternative for LDL-C reduction in these high risk patients.Item An evaluation of the use of G-CSF as an adjunct to IVF in women who have previously failed attempts at pregnancy with IVF(2017) Mohamed, TasneemBackground Recurrent IVF failures may result from implantation defects of which a thin endometrium is often implicated. Studies show that improved endometrial thickness increases the probability of successful IVF. Objectives To evaluate the effects of transcervical instillation of G-CSF as an adjunct to IVF. The study looked at the influence of G-CSF on the endometrium and on the achievement of pregnancy. Methods A retrospective cross-sectional study of women attending Bio ART Fertility Centre, who had two or more failed IVFs previously. Results There were a total of 49 women studied with a mean age of 38.9. Mean number of previous IVFs were 3.1. Comparison between those that achieved pregnancy and those that did not showed that age was a statistically significant factor (p-value 0.0005). Mean endometrial thickness pre and post-GCSF between the groups was not statistically significant (p-values >0.05). Conclusion With the use of G-CSF we achieved a clinical pregnancy rate of 34.69% and a statistically significant overall expansion of endometrial thickness (p-value 0.0029). However we failed to show any association between endometrial expansion and pregnancy outcome.Item Meta-analysis of intermittent treatment with sulfadoxine-pyrimethamine in pregnancy in malaria endemic areas(2002-11-02) Mkopi, Abdallah BakariTo systematically evaluate the efficacy of double dose of sulfadoxine-pyremithamine (SP/SP) treatment in pregnancy in malaria endemic areas. Methods - The relevant articles were retrieved by a computerized search of Medline, Cochrane Review, Pub Med and Google with the following key words, sulfadoxine-pyrimethamine, intermittent, pregnancy, Quasi- experimental studies and Randomised Control Trials. Three reviewers identified only 2 papers meeting the inclusion criteria set for the study. Systematic quantitative review was performed.Item Pregnancy outcomes in women receiving intrapartum epidural analgesia at the Chris Hani Baragwanath academic hospital a 6-month review(2017) Padayachee, VeneshreeObjectives This study had two objectives. The first was to describe the maternal outcomes and complications associated with epidural analgesia and the neonatal outcomes of babies born to women receiving intrapartum epidural analgesia. The second was to assess the progress of labour in women receiving epidural analgesia and the incidence of caesarean section and assisted vaginal deliveries. Study design This was a cross sectional retrospective descriptive study of all women who received intrapartum epidural analgesia and the neonates born thereof between 01/05/2015 and 31/10/2015. Methods Women who received intrapartum epidural analgesia were identified from the epidural registers at the Chris Hani Baragwanath Academic Hospital (CHBAH). The medical records of these women and their neonates were retrieved and the relevant data reviewed, captured and analysed. Results There were a total of 9305 women that delivered between 01/05/2015 and 31/10/2015, of which 302 received intrapartum epidural analgesia. The incidence of epidural use during this period was 3.24%. The median gestational age at delivery was 38.9 (37 - 42) weeks’ gestation. The incidence of epidural related complications was 17%, comprising of hypotension (13.4%) and other minor complications (3.6%) with no associated morbidity or mortality. Eighty-four (29.7%) of the women had poor progress of labour pre and post epidural and 13 (4.6%) women post epidural only. Oxytocin for augmentation of labour was used in 96 (32.8%) women. The incidence of prolonged second stage of labour was 26.9% with an average duration of 63 ±33 minutes, with a longer duration observed in primigravid women. There were 142 (50.2%) normal vaginal deliveries, 23 (8.1%) assisted vaginal deliveries and 118 (41.7%) caesarean sections, of which fetal distress (23%) was the main indication. v There were a total of 62 cardiotopographs (CTG), that changed from reactive to suspicious post epidural, of those 52 neonates were born with an Apgar score of >7. Of the 283 neonates delivered, 278 (98.2%) neonates were born alive with 258 (91.2%) neonates with Apgar scores of >7 and 23 (8.1%) with Apgar scores <7. The incidence of adverse neonatal outcomes was 4.2%. The fetal outcomes stratified by maternal, epidural and labour outcomes reflected neither associative nor causal relationship to adverse fetal outcomes. Conclusion At the CHBAH, intrapartum epidural analgesia uses resulted in a maternal complication rate of 17%, with no reported maternal morbidity or mortality. There was no statistical increase in the incidence of poor progress of labour, use of oxytocin and caesarean section or assisted vaginal deliveries. Two hundred and fifty eight (91.2%) neonates were born with Apgar scores of >7, and an adverse neonatal outcome rate of 4.2%. Therefore the benefits of epidurals analgesia outweigh the risks.Item An integrated approach to training of healthcare providers to improve the administration of intermittent preventive therapy for malaria in pregnancy in Kaduna State, Nigeria(2018) Nuhu, Simbiat SophiaBackground Intermittent Preventive Therapy using sulfadoxine pyrimethamine (IPTp-SP) is a malaria control strategy to reduce cases of malaria in malaria endemic countries. However, the administration of the recommended three doses of IPTp throughout the stages of pregnancy still remains low in Nigeria even though, Nigeria is a malaria endemic country. Quality improvement approach has been demonstrated to improve practice among healthcare providers. This study therefore used a quality improvement approach to train and coach healthcare providers in order to improve the administration of the recommended doses of IPTp to pregnant women receiving antenatal care (ANC) services. Methods A quasi-experimental study design was carried out to evaluate the effect of quality improvement approach consisting of training and coaching of healthcare providers to improve the administration of IPTp during ANC service. Primary Healthcare Centre (PHC) Samaru was purposively selected and twelve healthcare providers participated in the study. ANC daily register was reviewed pre-intervention, intervention and post-intervention period of the study. Data were analysed using line graphs and run charts. Results A total of 36 ANC visit weeks were observed between 21st November 2016 and 27th July 2017. The mean level for IPTp1 administration pre-intervention was 105.85% (SD: 29.28) and 75.20% (SD: 16.89) for IPTp2+. The levels of IPTp1 administration were relatively stable from Week 1 to Week 10 although, there was overestimation of IPTp1 as 8 of the 16 Weeks in the pre-intervention period i.e. Weeks 3, 5, 7, 8, 11, 13, 15 and 16 all had more than 100% of eligible women administered IPTp1. The patterns of IPTp2+ administrations shows the levels of IPTp2+ administration were erratic. There was evidence indicating the process of IPTp1 was relatively stable post-intervention as the data crosses the median line only six times i.e. 7 runs. This indicates that the process of IPTp1 was within normal variation over the post-intervention period. There was an upward shift showing immediate improvement of the administration of IPTp2+ post-intervention although, there was a non-random variation in the administration of IPTp2+. The iv improvements of IPTp were not sustainable due to stock-outs. The quality of the ANC daily register was poor. Conclusion The integrated training and coaching intervention approach improved the administration of the recommended three doses of IPTp within the context of a PHC. These findings should be interpreted with caution as the impact of the intervention may not have reached its full impact due to the short post-intervention assessment. Stock-outs remains a huge barrier to the administration of IPTp under DOT during ANC services. The data quality of the ANC daily register improved post-intervention however, there were still slight errors thus, indicating that healthcare providers need constant coaching. It is important to integrate training and coaching of healthcare providers in order to have desired and sustained outcomes. Keywords: Malaria in pregnancy, IPTp, IPTp-SP, SP, ANC, Pregnant women, Healthcare providers, administration, QI, integrated training and coaching.Item Outcomes of pregnant patients with cardiac disease at Chris Hani Baragwanath Academic hospital(2018) Mugwede, MaideiIntroduction: The incidence of cardiac disease in pregnancy ranges between 0.1 – 4.0%. It is the 5th leading cause of maternal deaths in South Africa. Management of pregnant cardiac patients involves pre-pregnancy counselling, with risk assessment and monitoring of the mother and fetus by a multidisciplinary team which includes an obstetrician, materno-fetal medicine subspecialist, cardiologist, neonatologist, geneticist and an anaesthetist. Objectives: To determine the maternal morbidity and mortality in cardiac patients presenting at Chris Hani Baragwanath Academic Hospital (CHBAH), as well as their neonatal outcomes and to obtain information about specific cardiac conditions in these patients, their obstetric management and the short-term effects of pregnancy on the underlying cardiac lesion. Methods: This was a prospective descriptive study where post-delivery cardiac patients were approached to enrol in the study from August 2013 to January 2014. Data was collected from the patients’ antenatal records and cardiology reports. Patients were also interviewed to determine more detailed information regarding previous pregnancy outcomes and cardiac complications which were not available in the antenatal records. Neonatal information was obtained by follow-up visits to the neonatal wards. Results: Acquired cardiac conditions accounted for 88.1% of the study patients (Rheumatic Heart Disease (RHD) 42.9% being the most common) while 11.9% were congenital. Most of the patients had a New York Heart Association (NYHA) class of I (85.4%) at antenatal booking. Of the participants in the study, 33.3% were human immunodeficiency virus (HIV) positive. Caesarean section accounted for 66.7% of v the deliveries while 33.3% were by normal vaginal delivery. There were 42.9% of women who experienced morbidities during their pregnancies with 27.5% suffering a decline in their NYHA class. Only eleven patients had a post-partum ECHO, in whom 82% showed a decline in the ejection fraction (EF). Intrauterine growth restriction (IUGR) complicated 44% of pregnancies. The perinatal mortality rate was 7%. There were no maternal deaths. Conclusion: Rheumatic heart disease is still the predominant underlying cardiac lesion. There is considerable maternal morbidity and perinatal morbidity and mortality in cardiac patients at CHBAH. The multidisciplinary team approach is improving the maternal and perinatal outcome in pregnant women with heart disease at CHBAH.Item Maternal nutrition during pregnancy and its association with birth outcomes and neonatal body composition in the context of HIV in urban Black South Africans(2018) Wrottesley, Stephanie VictoriaBackground: Maternal pre-pregnancy overweight and obesity and excessive gestational weight gain (GWG) are established predictors of fetal growth, which substantially increase the risk of adverse birth outcomes, such as high birth weight and large-for-gestational age deliveries. While sub-optimal growth in utero has serious implications for infant health in the short term, nutritional insults during this critical period of plasticity may additionally impair growth and development of body tissues and thereby, increase long-term risk of obesity and non-communicable diseases in later life. This double burden of malnutrition (maternal overweight coupled with micronutrient deficiencies) is of particular relevance to low-or middle-income countries, such as South Africa, where rapid urbanisation and a transition towards diets high in saturated fat, sugar, salt and processed foods and decreased levels of physical activity has resulted in substantial increases in obesity. Although the implications of anthropometrically defined maternal nutritional status (MNS) on birth size have been well established, the role of dietary patterns within these relationships has not been thoroughly examined. In addition, the use of birth weight as a proxy for fetal growth does not distinguish between the components of body composition (i.e. fat mass and fat-free mass), which may be more indicative of metabolic risk. Lastly, the influence of other maternal factors such as human immunodeficiency virus (HIV) on the associations between maternal nutrition and infant outcomes and metabolic risk is yet to be explored. Aim: The overall aim of this thesis was to examine maternal nutrition (nutritional status; dietary patterns) of urban, black South African women and explore the relationship between maternal dietary patterns during pregnancy and birth outcomes (including neonatal body composition). Furthermore, the extent to which other maternal factors – i.e. HIV/antiretroviral treatment (ART) status, body mass index (BMI) at recruitment, GWG, demographics, socioeconomic status etc. - act as confounders or effect modifiers to these associations was explored. The following four specific study components addressed this aim: 1) To review and report on MNS in African women and its associations with fetal, birth, neonatal and infant outcomes in the first 1000 days; 2) to compare body composition measurements using two methods, namely (i) dual-energy x-ray absorptiometry (DXA) and (ii) air displacement plethysmography (ADP; Peapod), in black South African neonates; 3) to characterise, depict and report on maternal dietary patterns during pregnancy using multivariate dimension-reduction techniques in urban black South African women and to examine the association between dietary patterns and GWG in the context of other maternal lifestyle and socioeconomic factors; and 4) to examine the associations between maternal dietary patterns and birth size and neonatal body composition and explore how specific maternal factors – i.e. HIV/ART status, maternal BMI and GWG – may influence these associations. Methods: Comprehensive literature searches were independently performed by two researchers in May 2015 in order to identify all relevant studies conducted in Africa. The review used a systematic approach to search the following databases: Medline, EMBASE, Web of Science, Google Scholar, ScienceDirect, SciSearch and Cochrane Library. Full-text articles were obtained and reviewed and data were extracted from relevant publications into tables appropriately. Within a wider longitudinal cohort study taking place in Soweto, Johannesburg (the Soweto First 1000-Day Study; S1000), habitual dietary intake of 538 pregnant women was assessed using a quantitative food-frequency questionnaire and dietary patterns were depicted via principal component analysis. Associations between dietary patterns and BMI-specific GWG were analysed using linear and multinomial logistic regression. ―Traditional‖ diet pattern adherence (pattern score) was used to classify maternal diet for the final study objective (objective 4) and multiple linear regression models were used to examine associations between maternal ―traditional‖ diet pattern score, HIV/treatment status [three groups: HIV negative, HIV positive (antenatal ART initiation), HIV positive (pre-pregnancy ART initiation)], BMI and GWG (kg/week) and: newborn (1) weight-to-length ratio (WLR, kg/m) in 393 mother-neonate pairs; (2) Peapod estimated fat mass index (FMI, kg/m3) in a 171-pair subsample. Results: Twenty-six studies met the inclusion criteria for the literature review (objective 1). Overall, MNS in Africa showed features typical of the epidemiological transition; including higher overweight and obesity and lower underweight prevalences, alongside high anaemia prevalences’ and poor-quality diets. Maternal BMI and GWG were positively associated with birth weight; however, maternal overweight and obesity were associated with both increased macrosomia (birth weight >4kgs) and intrauterine growth restriction risk. In addition, maternal anaemia was associated with lower birth weight and both macro- and micronutrient supplementation during pregnancy was associated with improvements in GWG, birth weight and mortality risk. During the comparison of body composition assessment techniques (objective 2), significant correlations were observed between ADP and DXA measurements of fat mass (r = 0.766; p<0.001), fat-free mass (r = 0.942; p<0.001) and %fat (r = 0.630; p<0.001). However, fat mass (408 ± 172 g vs. 337 ± 165 g; p<0.001) and body fat percentage (12.9 ± 4.4% vs. 9.9 ± 4%; p<0.001) were significantly higher and fat-free mass (2681 ± 348 g vs. 2969 ± 375 g; p<0.001) significantly lower when estimated by ADP than by DXA. There was greater consistency in the estimation of fat-free mass between the methods when compared to estimates of fat mass and body fat percentage. Longitudinal assessment (objectives 3 and 4) identified three dietary patterns in urban black South African women during pregnancy: namely ―western‖, ―traditional‖ and ―mixed‖. ―Western‖ and ―mixed‖ diet patterns were associated with 35 g/week (p=0.021) and 24 g/week (p=0.041) higher GWG in normal weight and obese women respectively. High intakes of the ―traditional‖ diet pattern were associated with a reduced odds of excessive weight gain in the total sample (OR: 0.81; p=0.006) and in normal weight women (OR: 0.68; p=0.003). In the final, fully adjusted study models, maternal obesity and GWG were associated with 0.25 kg/m (P=0.008) and 0.48 kg/m (P=0.002) higher newborn WLR, while ―traditional‖ diet pattern score was associated with lower newborn WLR (-0.04 per +1 SD; P=0.033). Additionally, ―traditional‖ pattern score was associated with 0.13 kg/m3 (P=0.027) and 0.32 kg/m3 (P=0.005) lower FMI in the total sample and in newborns of normal weight women, respectively. HIV positive (pre-pregnancy ART) vs. HIV negative (ref) status was associated with 1.11 kg/m3 (P=0.002) higher newborn FMI in a fully adjusted model. Conclusion: This thesis confirms the rapid transition in MNS across urban African populations and demonstrates the implications that the rise in maternal overweight and obesity alongside poor dietary patterns and micronutrient deficiencies may have on birth outcomes, as well as potentially on longer term health trajectories. However, it also highlights a lack of data on infant outcomes beyond birth, and therefore, a need for longitudinal data that examines longer-term implications in the African setting. In South Africa in particular, the thesis indicates that promotion of a traditional-style diet pattern - high in whole grains, legumes, vegetables and traditional meats and low in processed foods - alongside a healthy preconception weight in urban, black women would significantly improve both maternal and infant adiposity profiles. This may have substantial benefits in reducing long-term risk of non-communicable diseases in both current and future generations. However, the need for a holistic approach which incorporates other health and lifestyle determinants of growth and adiposity in the infant is critical in optimising metabolic health trajectories. In HIV-positive women for example, development of targeted monitoring and management strategies is necessary in order to limit the treatment-specific effects on adiposity in the newborn.Item Pre-eclampsia: the outcome of term pregnancies at Rahima Moosa Mother and Child Hospital(2015) Naidoo, KumeshaBackground Pre-eclampsia and its complications remain a significant cause of maternal and perinatal morbidity and mortality on a global level. There are few data regarding the maternal and fetal outcome of pre-eclampsia at term. Studies suggest that poor maternal outcome is more prevalent as one approaches term, while there are conflicting findings regarding the outcomes of the babies born to term pre-eclamptic patients. Objective To determine the prevalence of pre-eclampsia in term pregnancies at Rahima Moosa Mother and Child Hospital (RMMCH), a hospital that provides district and higher level referral services, and to assess the severity of maternal disease in pre-eclampsia at term, as well as fetal outcomes. Methods This was a prospective cross-sectional, descriptive study on women giving birth at term with pre-eclampsia. All women were followed up until delivery. The indication for and mode of delivery, maternal progress and complications, as well as fetal outcome, were recorded. Results Seventy-eight patients were entered into the study, giving a hospital prevalence rate of pre-eclampsia at term of 1.2%. The major maternal complications were those of severe hypertension (75.6%), eclampsia (9%), HELLP syndrome (3.8%), and pulmonary oedema (7.7%). There was one maternal death. Fifty-one patients (65%) delivered by caesarean section. Major fetal complications encountered were respiratory distress (7.5%) and birth asphyxia (3.7%). There was one neonatal death from meconium aspiration.