Perinatal Medical Care Research Articles

Method of separation and concentration of fetal nucleated red blood cells in maternal blood and its application to fetal diagnosis.

A fetal diagnostic method that is without risk to the embryo has been long awaited in the field of gene diagnosis. Establishment of non-invasive fetal diagnosis using maternal peripheral blood will greatly contribute to perinatal medical care. The lectin method that we have studied and developed selectively recovers nucleated red blood cells (NRBC) among fetal cells mixed in maternal peripheral blood. Maternal blood, 7 mL, was collected with ethylene diamine tetraacetic acid (EDTA) treatment in each week of gestation and subjected to preliminary concentration by density centrifugation (Histopaque [Histopaque-1077; Sigma Diagnostics, MO, USA], specific gravity: 1.095), and NRBC were separated and collected on slide glasses by the lectin method (soybean agglutinin [SBA]: 50 microg/mL). To investigate selective adhesion of the erythrocyte fraction, the SBA concentration was set to 50 microg/mL, and the cells were labeled with CD11a and CD33 (anti-white blood cell antibodies) and investigated by flowcytometry. Erythrocytes adhered at a high rate (87.0 +/- 9.7%) while the adhesion rates of granulocytes, monocytes, and lymphocytes were low, confirming the usefulness of the method for separation and recovery of the erythrocyte fraction. When recovery of NRBC was investigated using this method, a mean of 6.57 +/- 7.12 cells were recovered from 1 mL of maternal blood (May-Gluüwald-Giemsa stain). The number of recovered NRBC increased slowly with pregnancy, but differences were not significant. To confirm that recovered NRBC were derived from the fetus, NRBC were recovered by the lectin method in four patients suspected of 18 trisomy by echography and analyzed by fluorescence in situ hybridization. Three hybridization signals were detected in NRBC at a high frequency, showing that most cells were derived from the fetus and thus, fetal diagnosis may be possible. Since the procedure of the lectin method we have developed is simple, and high concentration efficiency can be obtained at a low cost, it may be clinically applicable.

Advances in perinatal medical care — from our experience

In the last 30 years, maternal and perinatal mortality rates have markedly improved in Japan. These results are supported by the advanced technologies and newly developed treatments in obstetric and neonatal medicine, the evidence of which will be described through the authors' experiences. Ultrasound-guided treatments for fetuses and pediatric surgery for extremely tiny infants have been performed with cooperation among cardiac surgeons, anesthesiologists and perinatologists. The remarkable achievements in neonatal medicine are surfactant replacement therapy, application of high frequency oscillation (HFO) respirator, nitric oxide and extracorporeal membrane oxygenation (ECMO) systems and transcutaneous blood gas monitoring. The possibility to have a safe pregnancy and delivery arose for women with severe medical complications such as diabetes mellitus (DM), heart diseases, and hemo-dialysis, factors formerly regarded as contraindications to pregnancy. The accumulative data of these high-risk pregnancies treated in our center are introduced. It is noted that molecular mechanisms in fetal growth have been elucidated to some extent. The insulin-like growth factor I (IGF-I) and IGF-binding protein 1 (IGFBP1) system, and cytokines, are involved in the fetal growth. Newly developed treatments such as urinary trypsin inhibitor (Urinastatin) for prevention of preterm delivery and amnioinfusion to cases of preterm premature rupture of the membrane are summarized. Finally, the reference to advanced medicine and its side effects lead to broad discussions regarding the future development of perinatal medicine.

Perinatal medical support in the area surrounding the Hanshin-Awaji earthquake.

After natural disaster, perinatal medical care must usually be provided from outside the disaster area, because most of the medical efforts inside the area focus on patients without special needs. This study reviews the emergency perinatal medical response after the great Hanshin-Awaji earthquake. In the present study, we summarize records of telephone calls and reports from the Neonatal Mutual Cooperative System (NMCS). The day of the earthquake, very little information was available to or from the disaster area. The day after the earthquake, Osaka City General Hospital (OCGH) and Osaka Medical Center and Research Institute for Maternal and Child Health were established as key facilities, and OCGH served as a center through which information passed to and from the disaster area. Most telephone calls to OCGH were placed on the second day after the earthquake by pregnant women concerned about their deliveries. Many high-risk pregnancies and newborn infants were transferred out of the disaster area over the next month. This analysis shows that although the emergency response was very rapid in this instance, the operation may be significantly improved in disasters of this magnitude: (i) if a communication mechanism able to serve a large volume is established; (ii) if helicopter transport was easily available; and (iii) if key facilities to handle communications were previously established so as to be available immediately.

Themes and Variations among Seven Comprehensive Perinatal Drug and Alcohol Abuse Treatment Models

In recent years, the prevalence of perinatal chemical dependency has become widespread, .crossing all ethnic and racial lines and every socioeconomic group (Chasnoff, Landress, & Barrett, 1990). Its potential effect on the health of women, children, families, and society has prompted support at the state and federal levels for comprehensive perinatal drug and alcohol treatment models (California Legislature, 1990; Doshan & Bursch, 1982; Graham & Timney, 1990; Jessup & Green, 1987; Novick, 1990; Reed, 1987; U.S. General Accounting Office, 1990). In California, legislation was enacted that funded a novel interdepartmental partnership within the California Health and Welfare Agency. The four agencies involved in this collaborative effort, called Options for Recovery (OFR), were the departments of Alcohol and Drug Programs, Developmental Services, Health Services, and Social Services. The OFR program provided comprehensive perinatal services to more than 2,600 individual pregnant or parenting women at seven pilot sites in both urban and rural parts of the state. The primary OFR program services included case management, residential and intensive outpatient treatment, perinatal medical care, and foster care services. These services were provided in a women-focused, women-sensitive manner to an ethnically and culturally diverse client population. The OFR program also emphasized coordinated service linkages both to prevent service duplication and to ensure that potential service gaps were not left unfilled. A state interagency task force, composed of representatives from the four collaborating state agencies responsible for the OFR program, was established to develop a statewide strategy for addressing the substance abuse treatment needs of pregnant and parenting women and their children. At each of the seven pilot sites, a local lead agency, accountable to the state, was given primary responsibility for implementing the OFR program. The management teams of each pilot project, which at a minimum consisted of alcohol and drug treatment program representatives and case management staff, reported to the local lead agency. Line staff who had ongoing responsibility for providing services for clients included drug and alcohol counselors, case managers, child development specialists, child care workers, parent educators, foster parent recruiters and trainers, mental health workers, and any other service provider that was part of the pilot's OFR program. An evaluation of the OFR program was conducted from 1991 to 1993. On the basis of information obtained through interviews, surveys, and focus groups with OFR staff, clients, and foster parents at all seven pilot sites, as well as quantitative data, the author identified a number of similar treatment and service themes and variations across all seven sites. This article describes both the commonalities and the differences observed during the course of the three-year evaluation. METHODS Qualitative Staff Data In-person interviews were conducted with members of the OFR State Interagency Task Force, staff from both the California Department of Alcohol and Drug Programs and alcohol and drug treatment programs at the local pilot project level, staff from each pilot's local lead agency, managerial and program staff at all pilot sites, foster parent recruiters and trainers, and county social services agency administrators. Interview questions focused on descriptive program information, program philosophy, indicators of success, service provision, staffing, interagency coordination, and program implementation. Program personnel at all seven pilot projects were also surveyed via self-administered, semi-structured survey questionnaires. The survey questions addressed the same issues as the interview as well as professional training and time management. Focus groups were conducted at 18 randomly selected provider sites from the pool of 73 treatment providers that participated in the OFR program. …

Present status and issues of perinatal medical care in Kyoto Prefecture

Present status and issues of perinatal medical care in Kyoto Prefecture

Birth‐weight‐adjusted infant mortality in evaluations of perinatal care: Towards a useful summary measure

Since birth-weight-specific infant mortality rates are widely considered to be measures of the effects of perinatal medical care, birth-weight-adjusted and birth-weight-specific infant mortality rates have often been used in comparisons across hospitals and geographic areas. Wilcox and Russell have provided a model which leads to the conclusion that birth weight adjustment is biased against populations with heavier birth weights and that birth-weight-specific infant mortality rates can yield misleading results. Nevertheless, evaluators and health planners still need a summary measure of the infant mortality rate in which some sort of birth weight adjustment is used to generate an (appropriately) weighted mean of birth-weight-specific relative risks. We used the 1983-85 national linked files of live births and infant deaths to investigate two new methods that extend the Wilcox-Russell approach, 'mean adjustment' and 'Z-adjustment', to compare birth-weight-specific infant mortality rates among the white populations of the states. Colorado was used as the reference population in logistic regression analyses. Statistical interactions between state and birth weight on the conventional kilogram scale, the mean-adjusted scale, and the Z scale were examined. There were substantial interactions with birth weight on all three scales. In addition, when Colorado was used as the reference population, mean adjustment shifted the odds ratios downward to implausibly low values, especially at lower weights. The Z-adjustment method incorporating the Wilcox-Russell approach appears to be a useful alternative to birth weight adjustment. However, because birth-weight-specific mortality rates do not differ uniformly across all birth weight groups, multiple summary measures are needed.

Cerebral Palsy in Children and Its Relationship with Perinatal Medical Care

Cerebral Palsy in Children and Its Relationship with Perinatal Medical Care

Severely Handicapped Children and Its Relationship with Perinatal Medical Care

Severely Handicapped Children and Its Relationship with Perinatal Medical Care

A descriptive study of epilepsy in the district of Copparo, Italy, 1964-1978.

Worldwide investigation of the epidemiology of epilepsy has suggested wide variations in the frequency of convulsive disorders. However, descriptive studies in general populations cannot be completely comparable because of a remarkable methodological dishomogeneity in definition of epilepsy, classification of seizures, and ascertainment, collection, and selection of the cases. The position with regard to the Mediterranean people was still little known, and the few studies presently available from Italy offer underestimates of epilepsy frequency owing to incompleteness in case-collection practices and lack of information about the incidence of the disease. Therefore, to verify the true frequency of epilepsy in our country, we performed a community-based epidemiologic study of convulsive disorders in the district of Copparo (population 45,153) in northern Italy. Based on 278 accepted cases with "active" epilepsy, the prevalence per 1,000 population on December 31, 1978, was 6.2 (6.4 if standardized to the Italian population). The average annual incidence for the period 1964 through 1978 was 33.1 per 100,000 (38.3 if standardized). These results, similar to those found in other Western countries, support the view that the frequency of epilepsy in Italy as a whole is higher than that indicated by the Italian studies previously published, and suggest that epilepsy is evenly distributed in Europe and the United States. Antecedents which could be considered potential causes of epilepsy were found in 39.6%, and in 39.1% of the prevalence and incidence cases, respectively; for both prevalence and incidence groups, perinatal brain injuries were the most frequent event. This high proportion of epileptic cases with underlying causes emphasizes the urgency of planning precautionary measures in Italy to improve prenatal and perinatal medical care.

Perinatal Mortality and Medical Care Effectiveness:

This article is concerned with using perinatal mortality as an indicator of the effectiveness of medical care. Perinatal mortality rates in various birthweight groups within the below 2,501 gram range are negatively correlated with perinatal mortality rates in the above 2,500 gram birthweight group. Areas with relatively high perinatal mortal ity rates among low-weight births tend to have relatively low perinatal mortality rates among higher weight births and vice versa. Mortality rates for all birthweights vary 2:1. When the above 2,500 gram birthweight group is considered, the range of variation between the best and worst is as great as 4:1. The association between 23 indicators of socioeconomic conditions and various crude and standar dized perinatal mortality rates is examined. Although low birthweight is piasitively correlated with socioeconomic disadvantage, standar dization for birthweight does not remove the association between overall perinatal mortality and many of the socioeconomic variables. Such variables commonly have a significant association with perinatal mortality among higher weight births, but no significant association with perinatal mortality among low-weight births or vice versa. Perinatal mortality rates covering all birth weight groups may well conceal important effects from the point of view of monitoring the effectiveness of the service provided.

Neonatal mortality: an analysis of the recent improvement in the United States.

To test the hypothesis that the recent substantial decline in the United States neonatal mortality rate (20.0/1000 in 1950 to 11.6/1000 in 1975) is associated with improvements in perinatal medical care, we examined this change in relation to the two primary components which determine neonatal mortality: birthweight distribution and birthweight-specific mortality. No improvement in the weight distribution of U.S. live births has occurred during this 25-year period, indicating that the change in neonatal mortality is attributable to improved survival for one or more birthweight groups. Decline in the mortality rate in the first 15 years was slow; three-fourths of the decline in the entire 25-year period occurred since 1965. With the exception of perinatal medical care, factors known to affect survival at a given birthweight have not changed in prevalence in the 25-year period. It is a plausible hypothesis that improved perinatal medical care is a major factor in declining neonatal mortality in the U.S.

Measuring the effectiveness of perinatal medical care.

An outcome-based index of the effectiveness of perinatal care was empirically tested using 3,441,448 linked birth-death records. In order to construct the index, an "expected" perinatal mortality rate was computed for 504 California hospitals, based on each newborn's birth weight, sex, race, and plurality. The index was then defined as the ratio of the observed mortality rate to that expected. From the sixteen-fold range observed in the unadjusted rates, a two-fold variation could be attributed to differentials in the efficacy of medical care. The remainder resulted from differences in patient risk and from binomial variations. The observed--expected ratio was observed to be significantly correlated with a number of traditional indicators of medical care quality. Multiple regression techniques revealed that the mortality ratio was significantly lower in larger delivery services, in urban hospitals, in hospitals performing above-average numbers of cesarean sections in those recording Apgar scores, and in hospitals having higher specialist-to-generalist ratios. Conversely, the ratio was significantly higher in hospitals with larger percentages of Spanish-surnamed mothers and in private proprietary hospitals. By separating the index into its observed and expected components, the regression model accounted for 82 per cent of the variance in the observed perinatal mortality rates.

Perinatal mortality rate at a community hospital, 1956 to 1975

This paper is a review of the perinatal mortality rate and its components, stillbirths and neonatal deaths, for the years 1956 through 1975 at Memorial General Hospital, Las Cruces, New Mexico. It is an attempt to assess major medical factors, such as specialization and cesarean section, and weigh their effect on these indices of the quality of perinatal medical care. Other factors considered in the analysis were: ages of mothers, parity, birth weights, and socioeconomic, educational, and motivational factors. The apparent impact of direct medical care factors is considerably less than would be expected.