Outcome In High Risk Pregnancies Research Articles

The ways of amniotic fluid sampling and its influence on lamellar body count

Even though artificial surfactant is now available, respiratory distress syndrome still remains a serious problem in neonatology. Prenatal analysis of the amniotic fluid can provide data giving insight into the fetal lung maturity, which enables planning of the further outcome of high-risk pregnancies. Surfactant prevents atelectasis by forming a layer rich in phospholipids between the air and liquid phase in alveoli thus leading to increased surface tension in them, which is a precondition for a good lung function after birth. Lamellar bodies are a form of stored surfactant, and their count in the amniotic fluid can be determined simply by a standard hematology analyzer. The method of determining lamellar body count has found an important place in prenatal diagnostics and is recommended as an initial method of a "cascade" procedure of testing fetal lung maturity. However, considering the importance of procedure of sample collection, storage and centrifugation, which can significantly affect the results obtained for the lung maturity, the amniotic fluid samples must be absolutely free of contamination with blood, meconium, mucus, bacteria and leucocytes.

P79 Value of third trimester uterine artery Doppler for prediction of adverse perinatal outcome in high risk pregnancies

International Journal of Gynecology & ObstetricsVolume 107, Issue S2 p. S433-S434 Poster presentations P79 Value of third trimester uterine artery Doppler for prediction of adverse perinatal outcome in high risk pregnancies L. Rai, L. RaiSearch for more papers by this authorL. Shivananda, L. ShivanandaSearch for more papers by this author L. Rai, L. RaiSearch for more papers by this authorL. Shivananda, L. ShivanandaSearch for more papers by this author First published: 20 November 2009 https://doi.org/10.1016/S0020-7292(09)61570-8AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume107, IssueS2Abstracts of XIX FIGO World Congress of Gynecology and ObstetricsOctober 2009Pages S433-S434 RelatedInformation

Perinatal outcome in high risk pregnancies.

To determine the perinatal outcome of high risk pregnancies, in terms of perinatal mortality, Apgar score, birth weight and neonatal complications in first week after birth. Cohort study. Obstetric Department of Sir Syed Trust Hospital, Karachi, from January to December 2007. All antenatal patients attending the Outpatient Department were interviewed, after informed consent. Those who fulfilled the required criteria were grouped in 2 categories; high risk (group A cases) and low risk (group B control) pregnancies according to the risk factors identified in the history. All singleton pregnancies from 28th weeks of gestation till delivery were included in the study. All pregnant women, who had multiple pregnancies or congenital malformations were excluded. Patients were followed till delivery and neonatal outcome was assessed in both the groups. Outcome measures were recorded. There were a total of 282 patients studied. The number of patients in group A were 162 and in group B, 120. Anaemia 98 (60.49%), pregnancy induced hypertension 24 (14.8%) and preterm labour 26 (16%) were identified as the major risk factors in group A. There were 12 (7.40%) stillbirths and 5 (3.08%) early neonatal deaths in group A, while there was 1 (0.84%) stillbirth and no neonatal death in group B (p=0.004, RR=1.72). There were 58 (35.80%) neonates with low birth weight in group A, while the same were only 4 (3.33%) in group B, which was statistically significant (p=0.001, RR=1.98). Poor Apgar score of < or = 7 at 1 minute was observed in 6 (4%) and at 5 min was observed in 5 (3.33%), while none of the neonates in group B was born with Apgar score of less < or = 7 at 1 or 5 minute (p=0.036, RR=1.83; p=0.068, tR=1.82 respectively). Meconium aspiration syndrome was observed in 7 (4.3%) cases in group A, and 2 (1.66%) in group B, which was statistically insignificant. Complication rate among the neonates was statistically not significant between the two groups. Perinatal mortality was twice as high in high risk group compared to low risk group. However, the complications in the neonates were statistically insignificant between the two groups.

Ultrasound of the Placenta: A Systematic Approach. Part II: Functional Assessment (Doppler)

Doppler velocimetry is the ideal clinical tool to assess placental performance in high-risk pregnancies. It also has value in predicting later complications and outcome in pregnancies which appear uncomplicated. All three circulations (fetal, placental and maternal) may be interrogated by Doppler technology. In the following review, we present basic physics aspects of Doppler and discuss mainly Doppler investigation of the fetal–placental circulation (umbilical artery, intraplacental circulation) as well as the uterine arteries. The assessment of umbilical blood flow provides information on blood perfusion of the fetal–placental unit. The diastolic blood flow velocity component in umbilical artery increases with advancing gestation. In pregnancies complicated by placental dysfunction, there may be a reduction in the number of functional villi and/or small blood vessels with, as a result, increased impedance, reflected, mainly, by a decrease in end-diastolic velocity. When the resistance increases even more, there is no diastolic forward velocity (absent end-diastolic velocity). Further increase in the resistance causes reversed end-diastolic velocity, which is considered a late step in the cascade of events leading to intrauterine fetal demise. Doppler assessment of the umbilical arteries was found to improve outcome of high-risk pregnancies, and reduce hospital admissions. On the contrary, routine Doppler ultrasound in low risk or unselected populations does not seem to confer benefit on mother or newborn. Uterine artery Doppler is a useful test in predicting pregnancies at high risk of developing complications related to uteroplacental insufficiency. It identifies women who may benefit from increased antenatal surveillance or prophylactic therapy. Three-dimensional power Doppler sonography can provide new insights into placental pathophysiology.

OC082: Comparison of the uterine artery score and the mean uterine artery PI in prediction of poor obstetric outcome

To assess test characteristics of the uterine artery score (UAS) and mean pulsatility index (PI) in prediction of poor obstetric outcome in high-risk pregnancies. Blood flow in the uterine arteries between 21 and 28 gestational weeks were studied in 157 high-risk women. The uterine artery score (UAS), as described by Hernandez-Andrade et al. (UOG 2002;19 : 438-42), was analysed in two ways; normal flow (UAS 0) vs. a positive score (UAS = 1 + 2 + 3 + 4) or low score (UAS = 0 + 1 + 2) vs. high score (UAS = 3 + 4). The mean uterine artery PI was divided into low mean PI (< 1.2) or high mean PI (> 1.2). Since high mean PI (> 1.2) and high UAS (3 + 4) occured in the same women, except for one, the analysis was restricted to a comparison between negative vs. positive UAS and low vs. high mean PI. Poor obstetric outcome was defined as preeclampsia or hypertension resulting in preterm delivery (< 37 weeks) or IUGR below the 3rd centile or placental abruption occuring at any gestational age. 56 (37%) women had preterm delivery (< 37 weeks) and 21 of them delivered because of preeclampsia or severe hypertension. There were no intrauterine fetal deaths, 2 cases of placental abruption and 3 children had isolated IUGR. In all, 42 (27%) women had cesarean section, and 23 (15%) of newborns were transferred to NICU. Positive UAS had sensitivity (DR) 76%, false positive rate (FPR) 32%, positive predictive value (PPV) 27% and likelihood ratio (LR) 2.4 for poor obstetric outcome. High mean PI had DR 48%, FPR 5%, PPV 59% and LR 9.3 for poor obstetric outcome. If poor obstetric outcome was restricted to preeclamptic pregnancies delivered < 34 weeks (9 of 152 women), mean PI had DR 78%, FPR 6%, PPV 44% and LR 12.3. Mean uterine artery PI is a reasonably good predictor for poor obstetric outcome. Notches in the velocity waveform do not seem to add much to the prediction of disease. Test characteristics are dependent on the study population and the definition of poor outcome.

Aufnahmekriterien nach dem G-BA-Beschluss: Definition, Interpretation und erste Schlussfolgerungen

The outcome of high risk pregnancies is better in tertiary hospitals. The German government introduced levels of perinatal care only in 2006. The aim of this study was to investigate how many children are to be expected for each level, taking the possible width of interpretation of the admission criteria into account. Perinatal quality assurance data from four German states (2005) were available. Based on the admission criteria used for level definitions, children were categorised into four different levels of care. To illustrate the possible width of interpretation of these admission criteria three analytical strategies were used. In addition, the distribution of children on different types of hospitals prior to the introduction of levels of care was analysed. Most deliveries (86-93 %) correspond to the lowest level, and only 1-5 % to the highest. Up to 15 % of children who should have been cared for in the highest level were born in hospitals with less than 500 annual deliveries. Among the neonates with risk profiles corresponding to the admission criteria for the two highest levels, up to 30 % were born in delivery units without NICUs. The majority (83 %) of attached NICUs had low caseloads (< 50 neonates < 1500 g / year). Most children fulfil the admission criteria for the lowest level of care whereas the need for specialised centres is rather low. Optimising the place of birth appropriately remains a challenge. Definition of levels of care based on admission criteria are difficult to implement due to a broad variety of interpretations.

Issues and Biases in Matching Medicaid Pregnancy Episodes to Vital Records Data: The Arkansas Experience

This study examines the extent of selection biases identified in the process of linking Medicaid claims with evidence of pregnancy to vital records. Two years of Medicaid claims were scanned to identify pregnancy-related diagnoses and procedures. Information on 55,764 Medicaid recipients was provided to the Division of Health Statistics, which linked the information to vital records data on a range of identifying characteristics. Claims were then clustered by date and then into episodes of care surrounding the birth date of the infant. We identified 38,222 pregnancy episodes matched to vital records; 8,474 episodes unmatched to vital records that appeared to terminate before a delivery; and 5,278 episodes that appeared to include a delivery but did not match to vital records. The characteristics of matched episodes and unmatched episodes and the characteristics of matched episodes with and without delivery claims are compared. Unmatched episodes spanned fewer weeks than matched episodes, included more diagnostic indicators of elevated risk, and occurred more frequently in more impoverished populations. Among the matched records, 13% did not include claims for delivery services. These episodes occurred more frequently among Hispanic women, women delivering out of hospitals and women with preterm births and infant deaths. The results provide evidence, as other studies have demonstrated, that matching Medicaid claims and vital records data is feasible. However, the matched analytic data set does tend to under-represent the outcomes of high-risk pregnancies. An additional source of selection bias can be avoided by using evidence of pregnancy as the Medicaid index for matching against vital records, rather than using only index cases with evidence of delivery.

Biophysical profile for fetal assessment in high risk pregnancies.

A biophysical profile (BPP) includes ultrasound monitoring of fetal movements, fetal tone and fetal breathing, ultrasound assessment of liquor volume with or without assessment of the fetal heart rate. The BPP is performed in an effort to identify babies that may be at risk of poor pregnancy outcome, so that additional assessments of wellbeing may be performed, or labour may be induced or a caesarean section performed to expedite birth. To assess the effects of the BPP when compared with conventional monitoring (CTG only or MBPP) on pregnancy outcome in high-risk pregnancies. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2007), CENTRAL (The Cochrane Library 2006, Issue 4), MEDLINE (1966 to November 2006), EMBASE (1974 to November 2006) and CINAHL (1980 to November 2006). Randomised and quasi-randomised controlled trials involving a comparison of fetal BPP with other forms of antepartum fetal assessment in women with high-risk pregnancies. Two authors independently assessed eligibility, quality and extracted data. We included five trials, involving 2974 women. Most trials were not of high quality. Although the overall incidence of adverse outcomes was low, available evidence from randomised controlled trials does not support the use of BPP as a test of fetal wellbeing in high-risk pregnancies. We found no significant differences between the groups in perinatal deaths (relative risk (RR) 1.33, 95% confidence interval (CI) 0.60 to 2.98) or in Apgar score less than seven at five minutes (RR 1.27, 95% CI 0.85 to 1.92). Combined data from the two high-quality trials suggest an increased risk of caesarean section in the BPP group RR 1.60, 95% CI 1.05 to 2.44, n = 280, interaction test P = 0.03. However, the number of participating women was relatively small (n = 280). Therefore, additional evidence is required in order to be definitive regarding the efficacy of this test in high-risk pregnancies. Furthermore, the impact of the BPP on other interventions, length of hospitalisation, serious short-term and long-term neonatal morbidity and parental satisfaction requires further evaluation. At present, there is insufficient evidence from randomised trials to support the use of BPP as a test of fetal wellbeing in high-risk pregnancies.

Transabdominal uterine artery Doppler between 11 and 14 weeks of gestation for the prediction of outcome in high-risk pregnancies

Objective. To assess the value of early transabdominal uterine artery Doppler ultrasound for the prediction of gestational outcomes in pregnancies at high risk for preeclampsia.Methods. This was an observational study. Doppler ultrasound of the uterine arteries at 11–14 weeks of gestation was performed in 76 women at high risk for preeclampsia. Abnormal uterine Doppler was defined by the presence of bilateral notching or by a mean resistance index (RI) >0.80. Adverse outcomes evaluated were preeclampsia, fetal growth restriction, placental abruption, intrauterine death, and complications requiring delivery before 34 weeks of gestation.Results. Among 76 women, 30 (39%) had abnormal uterine Doppler and 46 (61%) had normal Doppler waveform configuration and RI. Abnormal uterine flow was related to a significantly higher incidence of preeclampsia (17% vs. 0%; p = 0.0041), fetal growth restriction (27% vs. 0%; p = 0.0002), intrauterine death (13% vs. 0%; p = 0.0109), and iatrogenic preterm delivery (20% vs. 2%; p = 0.0086). When the Doppler was normal, the negative predictive value for complications requiring delivery before 34 weeks was 98%.Conclusions. Normal impedance to flow in uterine arteries between 11 and 14 weeks of gestation is strongly related to a normal pregnancy outcome in women at high risk for preeclampsia.

Doppler sonography: improving outcome in high risk pregnancy

Doppler sonography has become a principal diagnostic tool in antenatal care, and as a consequence the perinatal outcome of high risk pregnancies has significantly improved. As an ultrasound scan is able to show the severity of any fetal malformations in a high risk pregnancy, health care professionals are able to be alerted relatively quickly that a condition may need treatment and/or alter the management of a pregnancy. The timing of scans can also be of great consequence. Ultrasounds are able to pick up defects in very early periods of gestation and when acted upon can ensure that the mother is in a position to have a number of options open to her.

Transabdominal uterine arteries doppler between 11-14 weeks of gestation for prediction of outcome in high risk pregnancies

ObjectiveTo assess the value of early transabdominal uterine arteries Doppler ultrasound for prediction of gestational outcomes in pregnancies at high risk for preeclampsia.Study designObservational study. Doppler ultrasound of uterine arteries at 11-14 weeks' gestation was performed in 76 women. Presence of diastolic notch and resistance index (RI) were investigated. Abnormal uterine Doppler was defined by presence of bilateral notching or by mean RI > 0.80. Adverse outcomes evaluated were preeclampsia, fetal growth restriction, placental abruption, intrauterine death and complications associated with impaired placentation requiring delivery before 34 weeks of gestation.ResultsAmong 76 women 30 had abnormal uterine Doppler indices and 46 had normal RI and normal Doppler waveform configuration at 11-14 weeks' gestation. Abnormal uterine flow was related to a significantly higher incidence of preeclampsia (16.6% vs 0%; p= 0.0041), fetal growth restriction (26.6% vs 0%; p= 0.0002), intrauterine death (13.3% vs 0%; p= 0.0109) and iatrogenic preterm delivery (20% vs 2.15% ; p= 0.0087).Among pregnancies with normal Doppler indices no one was complicated by preeclampsia or fetal growth restriction. Normal waveform configuration had 97.8% of negative predictive value for complications requiring elective delivery before 34 weeks.ConclusionNormal Doppler indices in the first trimester are strongly related to normal outcome of pregnancy in women at high risk for preeclampsia. Results of this study support a change in the antepartum care of already identified high risk women with normal uterine Doppler waveform configuration at 11-14 weeks of gestation. ObjectiveTo assess the value of early transabdominal uterine arteries Doppler ultrasound for prediction of gestational outcomes in pregnancies at high risk for preeclampsia. To assess the value of early transabdominal uterine arteries Doppler ultrasound for prediction of gestational outcomes in pregnancies at high risk for preeclampsia. Study designObservational study. Doppler ultrasound of uterine arteries at 11-14 weeks' gestation was performed in 76 women. Presence of diastolic notch and resistance index (RI) were investigated. Abnormal uterine Doppler was defined by presence of bilateral notching or by mean RI > 0.80. Adverse outcomes evaluated were preeclampsia, fetal growth restriction, placental abruption, intrauterine death and complications associated with impaired placentation requiring delivery before 34 weeks of gestation. Observational study. Doppler ultrasound of uterine arteries at 11-14 weeks' gestation was performed in 76 women. Presence of diastolic notch and resistance index (RI) were investigated. Abnormal uterine Doppler was defined by presence of bilateral notching or by mean RI > 0.80. Adverse outcomes evaluated were preeclampsia, fetal growth restriction, placental abruption, intrauterine death and complications associated with impaired placentation requiring delivery before 34 weeks of gestation. ResultsAmong 76 women 30 had abnormal uterine Doppler indices and 46 had normal RI and normal Doppler waveform configuration at 11-14 weeks' gestation. Abnormal uterine flow was related to a significantly higher incidence of preeclampsia (16.6% vs 0%; p= 0.0041), fetal growth restriction (26.6% vs 0%; p= 0.0002), intrauterine death (13.3% vs 0%; p= 0.0109) and iatrogenic preterm delivery (20% vs 2.15% ; p= 0.0087).Among pregnancies with normal Doppler indices no one was complicated by preeclampsia or fetal growth restriction. Normal waveform configuration had 97.8% of negative predictive value for complications requiring elective delivery before 34 weeks. Among 76 women 30 had abnormal uterine Doppler indices and 46 had normal RI and normal Doppler waveform configuration at 11-14 weeks' gestation. Abnormal uterine flow was related to a significantly higher incidence of preeclampsia (16.6% vs 0%; p= 0.0041), fetal growth restriction (26.6% vs 0%; p= 0.0002), intrauterine death (13.3% vs 0%; p= 0.0109) and iatrogenic preterm delivery (20% vs 2.15% ; p= 0.0087).Among pregnancies with normal Doppler indices no one was complicated by preeclampsia or fetal growth restriction. Normal waveform configuration had 97.8% of negative predictive value for complications requiring elective delivery before 34 weeks. ConclusionNormal Doppler indices in the first trimester are strongly related to normal outcome of pregnancy in women at high risk for preeclampsia. Results of this study support a change in the antepartum care of already identified high risk women with normal uterine Doppler waveform configuration at 11-14 weeks of gestation. Normal Doppler indices in the first trimester are strongly related to normal outcome of pregnancy in women at high risk for preeclampsia. Results of this study support a change in the antepartum care of already identified high risk women with normal uterine Doppler waveform configuration at 11-14 weeks of gestation.

OP11.07: Intrapartum amniotic fluid index as predictor of perinatal outcome in high risk pregnancy

OP11.07: Intrapartum amniotic fluid index as predictor of perinatal outcome in high risk pregnancy

Doppler sonography: Improving outcome in high risk pregnancy

Doppler sonography has become a principal diagnostic tool in antenatal care, and as a consequence the perinatal outcome of high risk pregnancies has significantly improved. As an ultrasound scan is able to show the severity of any fetal malformations in a high risk pregnancy, health care professionals are able to be alerted relatively quickly that a condition may need treatment and/or alter the management of a pregnancy. The timing of scans can also be of great consequence. Ultrasounds are able to pick up defects in very early periods of gestation and when acted upon can ensure that the mother is in a position to have a number of options open to her.

The heart–brain interaction in the fetus: Cerebrovascular blood flow in the developing human

Fetal blood flow is influenced by multiple factors, including the structure of the heart and the impedance of the distal vascular beds. Many babies with congenital heart disease have restricted intrauterine growth, neurologic abnormalities, and poor neurodevelopmental outcome, independent of surgical intervention. The circulatory alterations that accompany specific anatomic cardiac defects may lead to predictable blood flow disturbances that affect normal brain development. Doppler measurements of vascular resistance in the cerebral circulation and calculations of resistance ratios that quantitate fetal blood flow distribution are altered in growth retarded fetuses and are predictive of growth retardation and poor perinatal outcome in high risk pregnancies. Fetuses with normal hearts but compromised placental perfusion have a compensatory redistribution of blood flow that is believed to enhance cerebral perfusion. This phenomenon, termed “brain sparing”, is due to a decrease in cerebral vascular resistance, which is likely initiated and controlled by an autoregulatory mechanism. Failure of this mechanism to adequately compensate for cerebral hypoxemia in fetuses with congenital heart disease may result in the disproportionate intrauterine growth and neurodevelopmental abnormalities that occur in many of these infants. Investigators have only begun to study whether “brain sparing” occurs in fetuses with congenital heart disease and to determine if alterations in cerebral perfusion impact on fetal neurodevelopment and postnatal neurologic outcome for these high-risk infants.

Fetal cerebral venous Doppler velocimetry in normal and high-risk pregnancy.

In previous pilot studies, fetal vein of Galen (GV) blood velocity has been shown to be non-pulsatile in normal pregnancies. A pulsating pattern in high-risk pregnancies has been related to adverse outcome of pregnancy. The aim of this study was to establish reference ranges for fetal cerebral venous blood flow and compare them to the recordings in high-risk pregnancies in terms of predicting adverse perinatal outcome. The GV, straight sinus (SS) and transverse sinus (TS) were located by color Doppler ultrasound in 189 normal pregnancies between 23 and 43 weeks of gestation. Recordings were also made in 102 pregnancies complicated by pregnancy-induced hypertension and/or intrauterine growth restriction. The following parameters were measured: peak systolic velocity, minimum diastolic velocity, time-averaged maximum velocity, pulsatility index for veins (PIV) and preload index (PLI). GV pulsations were noted. In high-risk pregnancies, Doppler measurements were correlated to pregnancy outcome, including emergency operative intervention and/or neonatal distress. Umbilical vein and umbilical, uterine and middle cerebral artery blood velocities were also recorded at the same time. In normal pregnancy, pulsating venous blood velocity was observed in GV in 8% of cases, in SS in 79% of cases and in TS in 100% of cases. GV and SS maximum velocity increased with gestational age and TS-PIV showed linear decreasing values and TS-PLI showed increasing values with gestational age. In high-risk pregnancies, pulsating blood velocity in the GV was found in 59 (58%) cases and was related to adverse outcome of pregnancy including mortality. Abnormal values for TS-PIV and PLI and SS maximum velocity were found in nine, six and five cases, respectively and were only related to perinatal mortality. GV pulsations were more frequent than umbilical venous pulsations. Of the fetal cerebral veins studied, the presence of pulsations in the GV seems to be the best predictor of adverse outcome of high-risk pregnancy. Pulsations in the GV are more frequent than in the umbilical vein and might therefore appear earlier during worsening fetal condition, and thus be of potential value for fetal surveillance in high-risk pregnancies.

Association Between First-Trimester Maternal Serum Pregnancy-Associated Plasma Protein-A and Adverse Pregnancy Outcome

Pregnancy-associated plasma protein-A (PAPP-A) is a glycoprotein derived from trophoblasts that cleaves insulin-like growth factor-binding proteins and augments the action of insulin growth factor. Maternal levels of PAPP-A are higher in primigravid and multiple pregnancies, and correlate positively with placental weight. Apart from being a marker of aneuploidy, low PAPP-A levels could be evidence of impaired placental formation and implantation. This retrospective review attempted to determine whether first-trimester PAPP-A levels are associated with intrauterine growth restriction, preterm delivery, or stillbirth. Pregnancy outcomes were sought in a medical records review and by postal questionnaire. All 827 women having serum PAPP-A estimates had a normal karyotype. Along with 2 neonatal deaths and 6 intrauterine deaths, 13 newborn infants had a birth weight below the third percentile and 55 weighed below the 10th percentile. Ninety-six women delivered prematurely. Four of the 6 intrauterine deaths were associated with a low maternal serum PAPP-A level less than 0.5 multiples of the median (MOM). Infant mortality was 3.8% in pregnancies with a PAPP-A level less than 0.5 MOM and 0.27% in those with higher levels for a relative risk of 13.75. Low levels of PAPP-A were associated with birth weight below the 10th percentile, but not with weight below the third percentile. Low maternal PAPP-A levels did not correlate with preterm delivery. This study indicates that low first-trimester levels of PAPP-A in maternal serum are associated with adverse fetal outcomes, including fetal death in utero and intrauterine growth retardation. An estimate of PAPP-A, by itself or combined with antenatal ultrasonography, might help assess the risk of such outcomes in high-risk pregnancies.

The Role of the Hospital of Birth on Survival of Extremely Low-birthweight, Extremely Preterm Infants

After completing this article, readers should be able to: 1. Explain the differences between population-based and institutional-based outcome studies of extremely low-birthweight (ELBW)/extremely preterm (EPT) infants. 2. Define three commonly used mortality/survival outcome measures for neonatal intensive care unit admissions. 3. Explain the role of population-specific factors in the survival potential of ELBW/EPT infants. 4. Explain the role of selection bias for maternal and neonatal transport in site-of-care mortality/survival statistics for ELBW/EPT infants. 5. Explain the role of the hospital of birth in current survival statistics for United States ELBW/EPT infants. Advances in perinatal health care in the past 15 years have resulted in a marked decrease in neonatal mortality throughout the industrialized world. Prior to the late 1980s, the greater portion of improved survival among preterm infants occurred primarily in infants older than 28 weeks’ gestation at birth. Refinements in the design and operation of mechanical ventilators and intravenous nutrition support, the implementation of continuous pulse oximetry monitoring, and the introduction of medical closure of the patent ductus arteriosus with indomethacin and of surfactant replacement therapy for respiratory distress syndrome have been major contributors to the improved survival in recent years among more immature infants (<28 weeks’ gestation). In addition, use of antenatal steroid therapy for induction of lung maturity and tocolytics to delay delivery as well as aggressive management of maternal medical and obstetric complications of pregnancy have been associated with decreased severity of illness in extremely preterm infants. The organization of perinatal health services into regional networks improved the outcome of high-risk pregnancies in the 1970s. However, in the United States, during the recent time of advances in perinatal health care capabilities, regional organization was dismantled in many states due, in large part, to the economics of health care funding. There followed a proliferation of community hospital-based neonatal intensive care units (NICUs) …

Fetal superior mesenteric artery blood flow velocimetry in normal and high-risk pregnancy.

To record blood flow velocimetry in the fetal superior mesenteric artery in normal pregnancy and to evaluate if blood flow recordings in the vessel might predict adverse outcome in high-risk pregnancy. The fetal superior mesenteric artery blood velocimetry was recorded in a cross sectional manner in 75 normal pregnancies between 27 and 41 weeks of gestation. Reference curves were performed for pulsatility and resistance indices. The superior mesenteric artery was also located in 48 singleton pregnancies complicated by pregnancy-induced hypertension and/or intra-uterine growth retardation. Middle cerebral artery, umbilical artery and vein and uterine artery velocimetry were also recorded. Superior mesenteric artery PI and RI values expressed an increase in resistance to blood flow with gestational age after 32 weeks of gestation. In all except eight high-risk pregnancies the fetal mesenteric artery PI values were within normal range. Among the pregnancies with absent or reversed blood flow in the umbilical artery, all had abnormal mesenteric artery pulsatility index (PI) (> 97.5th percentiles), one fetus died intrauterine and two others died after delivery due to prematurity, growth retardation and necrotizing enterocolitis. In the remaining fetuses with increased mesenteric artery PI, necrotizing enterocolitis was diagnosed in three cases. Increased vascular resistance in the mesenteric artery might be a late sign of fetal circulation redistribution and frequently related to necrotizing enterocolitis in the newborn.

Blood velocity in the fetal vein of Galen and the outcome of high-risk pregnancy

Background: Pulsation in the flow velocity waveform in the umbilical vein is related to perinatal mortality but the flow velocity waveform in the fetal vein of Galen is normally even and without fluctuation. Objectives: To establish whether blood flow velocity pulsations in the vein of Galen in high-risk pregnancies are related to outcome. Study Design: The vein of Galen was located by colour Doppler ultrasound in 102 pregnancies complicated by severe pregnancy-induced hypertension. The blood velocity waveform was recorded by pulsed Doppler within 2 days of delivery and the presence pulsations related to pregnancy outcome, including emergency operative intervention and neonatal distress. Umbilical artery and vein and uterine artery blood flow velocity waveform were also recorded at the same time. The clinicians managing the women were unaware of the venous flow results. Results: Pulsation were present in the vein of Galen in 68 cases and in the umbilical vein in 21. Both were significantly related to adverse outcome. Pulsations in the vein of Galen were seen in all seven perinatal deaths. Conclusions: Since umbilical venous pulsation are a late sign of fetal compromise, and pulsations in the vein of Galen seem to appear earlier, thus being an intermediate sign of fetal compromise that might be of great value for fetal surveillance.

The interplay between ethnicity and free access to perinatal care

Ethnicity accounts for genetic, environmental, lifestyle and reproductive variables 1 . Different outcome of high-risk pregnancies among different ethnic groups was usually ascribed to variable access to medical care. Since access to perinatal care is free for the entire population in Israel, we examined if ethnic differences have an effect on birth weight of twins. Data of all deliveries in Israel during 1993 1998 obtained through the Central Bureau of Statistics Ž was used to select 12 567 pairs of Jewish n 9676, . Ž . 77% and Muslim n 2557, 20.3% mothers with Ž . known maternal parity 98.3% . We used the Microsoft Excel and True Epistat programs for statistical analysis. During the study period, we observed a consistent rise in the number of twin births among