The World Health Organization Antenatal CorTicosteroids for Improving Outcomes in preterm Newborns (ACTION-III) Trial: study protocol for a multi-country, multi-centre, double-blind, three-arm, placebo-controlled, individually randomized trial of antenatal corticosteroids for women at high probability of late preterm birth in hospitals in low- resource countries

BACKGROUND

Preterm birth complications are the leading cause of newborn and under-5 mortality. Over 85% of all preterm births occur in the late preterm period, i.e. between 34 and < 37 weeks of gestation. Antenatal corticosteroids (ACS) prevent mortality and respiratory morbidity when administered to women at high risk of an early preterm birth, i.e. < 34 weeks' gestation. However, the benefits and risks of ACS in the late preterm period are less clear; both guidelines and practices vary between settings. Emerging evidence suggests that the benefits of ACS may be achievable at lower doses than presently used. This trial aims to determine the efficacy and safety of two ACS regimens compared to placebo, when given to women with a high probability of late preterm birth, in hospitals in low-resource countries.

METHODS

WHO ACTION III trial is a parallel-group, three-arm, individually randomized, double-blind, placebo-controlled trial of two ACS regimens: dexamethasone phosphate 4 × 6 mg q12h or betamethasone phosphate 4 × 2 mg q 12 h. The trial is being conducted across seven sites in five countries-Bangladesh, India, Kenya, Nigeria, and Pakistan. Eligible women are those with a gestational age between 34 weeks 0 days and 36 weeks 5 days, who have a high probability of preterm birth between 12 h and 7 days (up to 36 weeks 6 days gestation). The primary outcome is a composite of stillbirth or neonatal death within 72 h of birth or use of newborn respiratory support within 72 h of birth or prior to discharge from hospital, whichever is earlier. Secondary outcomes include safety and health utilization measures for both women and newborns. The sample size is 13,500 women.

DISCUSSION

This trial will evaluate the benefits and possible harms of ACS when used in women likely to have a late preterm birth. It will also evaluate a lower-dose ACS regimen based on literature from pharmacokinetic studies. The results of this trial will provide robust critical evidence on the safe and appropriate use of ACS in the late preterm period internationally.

TRIAL REGISTRATION

ISRCTN11434567 . Registered on 7 June 2021.

Prospective cohort study of prevention of mother to child transmission of hepatitis B infection and 9 months follow-up of hepatitis B-exposed infants at Ile-Ife, Nigeria

OBJECTIVES

Eliminating mother-to-child transmission (MTCT) of hepatitis B virus (HBV) is central to WHO's target of reducing hepatitis B infection in children to &lt;0.1% by 2030. While Nigeria accounts for 8.3% of the global burden, interventional studies on prevention of MTCT of HBV are hardly available. This study aimed to assess the impact of prevention of MTCT interventions on vertical transmission of HBV among pregnant women in Nigeria.

DESIGN

A prospective cohort study.

SETTING

A University Teaching Hospitals Complex in Nigeria between 2015 and 2021.

PARTICIPANTS

10 866 pregnant women and their pre-existing children.

INTERVENTIONS

Eligible pregnant women were screened for HBsAg using chromatographic immunoassay (Micropoint, USA). HbsAg-positive women had HBV serological assay done and their pre-existing children were screened. Women with HBV DNA ≥2 00 000 IU/mL and those positive for hepatitis B e-antigen (HBeAg) had 300 mg/day of Tenofovir Disoproxil Fumarate (TDF) in the third trimester. The newborns had hepatitis B vaccines and HB immunoglobulin (HBIG) administered, followed by testing for HBsAg at 9 months postnatally.

PRIMARY OUTCOME MEASURES

Prevalence of chronic hepatitis B infection in pregnancy, and the incidence of MTCT of HBV.

RESULTS

Overall, 395 women had chronic HBV infection, giving a prevalence of 3.64%. Their mean age was 31.51±5.71 years, with a median parity of 1.2. Thirteen women (5.2%) were positive for HBeAg, seven (3.1%) of the 225 pre-existing hepatitis B-exposed children were HbsAg positive and 17 women had prenatal TDF. Overall, 376 women completed the study, with mean birth weight of 3.21±1.86 kg and perinatal mortality rate of 29.2/1000 births. Hepatitis Bvaccine-HBIG combination was administered to 260 newborns, while the others had hepatitis B vaccine alone. All the children tested negative to the HbsAg at 9 months.

CONCLUSION

Eliminating MTCT of HBV infection through validated protocols in low and middle income countries with the highest burden of chronic HBV infections is feasible. National scale-up of such protocols is recommended.

A modern-day experience with Brunschwig's operation: Outcomes associated with pelvic exenteration

OBJECTIVE

To evaluate postoperative and oncologic outcomes associated with pelvic exenteration for non-ovarian gynecologic malignancies.

METHODS

This was a retrospective review of patients who underwent pelvic exenteration for non-ovarian gynecologic malignancies at our institution from 1/1/2010-12/31/2019. Palliative exenteration cases were excluded from survival analysis. Postoperative complications were early (≤30 days) or late (31-180 days). Complications were graded using a validated institutional scale. Major complications were considered grade ≥ 3. Categorical variables were compared using the chi-square test, and the Kaplan-Meier method was used for survival analysis.

RESULTS

Of 100 patients identified, 89 underwent pelvic exenteration for recurrent disease, 5 for palliation, 5 for primary disease, and 1 for persistent disease. Thirty percent had cervical, 27% vulvar, 24% uterine, and 19% vaginal cancer. Sixty-two percent underwent total, 30% anterior, and 8% posterior exenteration. No deaths occurred intraoperatively or within 30 days of surgery. Six patients died after 30 days. Ninety-seven experienced a perioperative complication-49 early, 1 late, and 47 both. Fifty experienced a major complication-22 (44%) early, 19 (38%) late, and 9 (18%) both. No variables were statistically associated with complication development. The 3-year progression-free survival rate was 61.0%; the 3-year overall survival rate was 61.6%. Of 58 surviving patients, 16 (28%) and 4 (7%) were alive after 5 and 10 years, respectively.

CONCLUSION

The overall complication rate for pelvic exenteration remains high. No variables demonstrated association with complication development as the rate was nearly 100%. The low rate of perioperative mortality is likely due to improved perioperative care.

A prospective study of severity of complications associated with use of misoprostol and other abortion methods in South West Nigeria

OBJECTIVES

To assess the severity of complications following misoprostol used to induce abortion compared with other methods among women admitted for postabortion complications.

METHODS

A cross-sectional study of women who presented with complications of induced abortion at nine secondary and tertiary hospitals in South West Nigeria between April 1, 2013 and May 31, 2014. Face-to-face interviews were conducted and information on the current admission was extracted from patient records. Associations between abortion method used and severity of abortion complications were evaluated using χ² and Fisher exact tests.

RESULTS

Of 522 women included in the study, 177 reported an induced abortion: 41 women (23.2%) had used misoprostol at the first attempt to induce abortion, whereas 79 (44.6%) women had undergone surgical abortion. Occurrence of fever (P=0.06), bleeding (P=0.3), and lower abdominal pain (P=0.32) was not significantly different between the misoprostol and surgical abortion/other methods groups. Severe complications were rare with misoprostol, but more common among women in the surgical abortion/other methods group. Maternal mortality occurred only among women in the surgical abortion/other methods group.

CONCLUSION

Use of misoprostol for induced abortion was associated with fewer complications and no maternal mortality compared with surgical abortion/other methods.

Narratives of women presenting with abortion complications in Southwestern Nigeria: A qualitative study

Unsafe abortion continues to impact negatively on women’s health in countries with restrictive abortion laws. It remains one of the leading causes of maternal mortality and morbidity. Paradoxically, modern contraceptive prevalence remains low and the unmet need for contraception continues to mirror unwanted pregnancy rates in many countries within sub-Saharan Africa. This qualitative study assessed women’s knowledge; their expectation and experiences of the methods employed for abortion; and their health care-seeking decisions following a complicated abortion. Women who presented with abortion complications were purposively sampled from seven health facilities in south-west Nigeria. In-depth interviews were conducted by social scientists with the aid of a semi-structured interview guide. Coding schemes were developed and content analysis was performed with WEFTQDA software. Thirty-one women were interviewed. Misoprostol was used by 16 women; 15 women used other methods. About one-fifth of respondents were aged ≤ 20 years; almost one-third were students. Common reasons for terminating a pregnancy were: “too young/still in school/training”; “has enough number of children”; “last baby too young” and “still breastfeeding”. Women had little knowledge about methods used. Friends, nurses or pharmacists were the commonest sources of information. Awareness about use of misoprostol for abortion among women was high. Women used misoprostol to initiate an abortion and were often disappointed if misoprostol did not complete the abortion process. Given its clandestine manner, women were financially exploited by the abortion providers and only presented to hospitals for post-abortion care as a last resort. Women’s narratives of their abortion experience highlight the difficulties and risks women encounter to safeguard and protect their sexual and reproductive health. To reduce unsafe abortion therefore, urgent and synergized efforts are required to promote prompt access to family planning and post-abortion care services.

Prevalence and obstetric outcome of women with red cell antibodies in pregnancy at the Leeds Teaching Hospitals NHS Trust, West Yorkshire, England

OBJECTIVE

The prevalence of red cell antibodies in pregnancy varies with ethnicity and geographical location, while the obstetric outcome depends on the available standard of care. Despite being the tertiary fetal medicine centre in West Yorkshire, the prevalence of red cell antibodies, and the outcome of pregnancies associated with these antibodies at the Leeds University Teaching Hospitals Trust remains unreported. This article aims to provide this information for the purpose of patient education and counselling.

STUDY DESIGN

The data of pregnant women with red cell antibodies between January 2011 and December 2016 was obtained from the Trust's database and reconciled with the Fetal Medicine Unit records using Viewpoint©. Fetal anaemia requiring in utero transfusion (IUT) was defined as a Middle Cerebral Artery Peak Systolic Velocities ≥ 1.5multiple of the median expected for gestational age. The mean gestational age at delivery, and perinatal outcomes of the pregnancies were recorded.

RESULT

Overall, 398 of the 96, 692 pregnant women that were screened had red cell antibodies, giving a prevalence of 1: 242 pregnancies. The Anti- E and Anti-M antibodies were the most common (114 women; 28.6%, and 112 women; 28.1% respectively), but did not cause fetal anaemia in isolation, while anti-D alloimmunization was the predominant indication for in-utero transfusion (IUT). Anti-DE and anti-Kell antibodies had the highest mean number of transfusions per pregnancy. The mean gestational age at delivery was 34 ± 2weeks. Post-transfusion fetal demise was recorded in two hydropic fetuses, both at a gestational age of 25 weeks; giving a transfusion-related mortality rate of 2.5%.

CONCLUSION

The prevalence of red cell antibodies at West Yorkshire is lower compared with reports from other Caucasian populations.Nevertheless, these antibodies are important causes of iatrogenic preterm delivery and fetal morbidity. The prognosis is however good with prompt diagnosis and management.

Trends in misoprostol use and abortion complications: A cross-sectional study from nine referral hospitals in Nigeria

Objective

The study aimed to assess the use of misoprostol and complications associated with abortions in referral hospitals in Nigeria, a country with restrictive abortion laws.

Methods

A cross-sectional study at nine referral hospitals in South-west Nigeria. Nine years’ data were retrieved from medical records, including 699 induced abortions. Independent variable was the method of abortion; dependent variables were complications, need for treatment and mortality. Statistical significance was tested with Chi-square, Fishers’ exact and chi-square for trend tests (p<0.05).

Results

There were 699 induced abortions amongst 2,463 abortions found in records. Nearly 70% were surgical abortions, but misoprostol use significantly increased over the study period in a linear trend (Χ² trend: 30.96, P <0.001). Patients who used misoprostol were significantly less likely to have infectious morbidity, genital tract injuries or medical complications. There was no difference in incomplete abortion in the groups. Patients were more likely to have in-patient care with surgical abortions (p<0.001), to need prolonged antibiotic regimens (p = 0.003), need further surgeries or additional specialist care (p = 0.009).

Conclusion

Misoprostol abortion has significantly increased over time, and was associated with less morbidity and need for further treatment, in this study. It appears to be the safer option.