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Ghesquière L, Moreeuw M, Drumez E, Gilbert M, Hanssens S, Védé M, Garabedian C. [Is it possible to safely reduce the use of in utero pH in the delivery room? Analysis of practices]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:270-274. [PMID: 36931599 DOI: 10.1016/j.gofs.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/04/2023] [Accepted: 03/08/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To evaluate our clinical practices since the implementation of different tools to reduce the use of pH in utero (pHiu) in the delivery room. METHODS A single-centre retrospective study was conducted in our university maternity hospital of Lille from October 2016 to March 2021. All patients in labour with a vaginal delivery agreement, a fetus in cephalic presentation and no contraindication to perform a pHiu were included. Since 2019, team training in fetal heart rate interpretation and a change in birth room practices with the introduction of fetal scalp pacing have been implemented to reduce the use of pH in utero. In order to evaluate the impact on clinical practices, the rate of pHiu, the number of pHiu performed per patient, the rates of instrumental deliveries, caesarean sections and pH at birth below 7.0 were studied and compared over time. RESULTS In total, 1515 patients had one or more pHiu during our study period, i.e. 7.3% (1515/20,562). The rate of pHiu decreased significantly from 2016 to 2021: in 2016, 12.1% (142/1171) of our sample had a pHiu during their labour, compared to 3.4% (33/963) in 2021. pH < 7.0 remained stable, ranging from 1.6 to 2.2%. Similarly, the rates of instrumental deliveries and caesarean sections remained stable, ranging from 17.7% to 21% and from 9.8% to 11.6%, respectively. CONCLUSION Improved knowledge of fetal physiology, awareness of teams of the limits of pHiu and introduction of fetal scalp stimulation have led to a decrease in the number of pHiu, without an increase in the rates of neonatal acidosis, instrumental deliveries and caesarean sections.
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Affiliation(s)
- Louise Ghesquière
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France; ULR 2694 - METRICS : évaluation des technologies de santé et des pratiques médicales, CHU de Lille, University of Lille, 59000 Lille, France.
| | - Marine Moreeuw
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Elodie Drumez
- ULR 2694 - METRICS : évaluation des technologies de santé et des pratiques médicales, CHU de Lille, University of Lille, 59000 Lille, France; Department of Biostatistics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Mélissa Gilbert
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Sandy Hanssens
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Morgane Védé
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Charles Garabedian
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France; ULR 2694 - METRICS : évaluation des technologies de santé et des pratiques médicales, CHU de Lille, University of Lille, 59000 Lille, France
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Giovannini E, Bonasoni MP, Pascali JP, Giorgetti A, Pelletti G, Gargano G, Pelotti S, Fais P. Infection Induced Fetal Inflammatory Response Syndrome (FIRS): State-of- the-Art and Medico-Legal Implications-A Narrative Review. Microorganisms 2023; 11:microorganisms11041010. [PMID: 37110434 PMCID: PMC10142209 DOI: 10.3390/microorganisms11041010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/21/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023] Open
Abstract
Fetal inflammatory response syndrome (FIRS) represents the fetal inflammatory reaction to intrauterine infection or injury, potentially leading to multiorgan impairment, neonatal mortality, and morbidity. Infections induce FIRS after chorioamnionitis (CA), defined as acute maternal inflammatory response to amniotic fluid infection, acute funisitis and chorionic vasculitis. FIRS involves many molecules, i.e., cytokines and/or chemokines, able to directly or indirectly damage fetal organs. Therefore, due to FIRS being a condition with a complex etiopathogenesis and multiple organ dysfunction, especially brain injury, medical liability is frequently claimed. In medical malpractice, reconstruction of the pathological pathways is paramount. However, in cases of FIRS, ideal medical conduct is hard to delineate, due to uncertainty in diagnosis, treatment, and prognosis of this highly complex condition. This narrative review revises the current knowledge of FIRS caused by infections, maternal and neonatal diagnosis and treatments, the main consequences of the disease and their prognoses, and discusses the medico-legal implications.
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Affiliation(s)
- Elena Giovannini
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Maria Paola Bonasoni
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Jennifer Paola Pascali
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35127 Padova, Italy
| | - Arianna Giorgetti
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Guido Pelletti
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Giancarlo Gargano
- Neonatal Intensive Care Unit, Azienda USL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Susi Pelotti
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Paolo Fais
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
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Dupuis H, Ghesquière L, Pierache A, Subtil D, Houfflin-Debarge V, Garabedian C. Evaluation and impact of fetal physiology training on fetal heart rate analysis. J Gynecol Obstet Hum Reprod 2021; 50:102185. [PMID: 34129991 DOI: 10.1016/j.jogoh.2021.102185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Evaluation of fetal well-being during labor is based on fetal heart rate (FHR) analysis, which requires physiology expertise. The aim of the present study was to assess medical residents' fetal physiology training in terms of theoretical knowledge, FHR interpretation, and use of second-line examinations. METHODS This single-center, prospective study of obstetrics and gynecology residents (N = 34) at CHU de Lille Hospital (Lille, France) was conducted from November 2017 to November 2018. Evaluation and training were conducted in three stages. First, residents' pre-training knowledge of FHR interpretation and use of fetal scalp blood sampling (FBS) was assessed using clinical cases. Second, a didactic training session on fetal physiology was delivered. Finally, post-training knowledge was evaluated using the same cases presented during pre-training. I: Pre-training, 3%, 11.8%, and 14.7% of residents considered their training on fetal physiology, FHR analysis, and second-line examinations, respectively, to be sufficient. Training significantly improved their theoretical knowledge, which was assessed using multiple-choice questions (median [interquartile range]: 1.5 [1.0-2.0] vs. 4.0 [3.0-4.5], p<0.001), and reduced the number of FBS requested (36.3% vs. 29.5%, p = 0.002). Krippendorff's alpha coefficient for the reproducibility of residents' responses improved significantly, reflecting greater homogenization of clinical practice decisions (alpha [95% confidence interval]: 0.60 [0.55-0.65] vs. 0.72 [0.67-0.76]). CONCLUSION Improved fetal physiology knowledge promotes more accurate FHR interpretation, better indications for second-line examinations, and greater homogenization of clinical practice decisions. Future studies should evaluate the impact of fetal physiology training on clinical practice.
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Affiliation(s)
- H Dupuis
- Univ. Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France.
| | - L Ghesquière
- Univ. Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France
| | - A Pierache
- Univ. Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, EA 2694 - Public Health: epidemiology and quality of care, F-59000 Lille, France
| | - D Subtil
- Univ. Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France
| | - V Houfflin-Debarge
- Univ. Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France
| | - C Garabedian
- Univ. Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France
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Dupuis H, Ghesquière L, De Jonckheere J, Aubry E, Sharma D, Deruelle P, Storme L, Houfflin-Debarge V, Garabedian C. When should foetal pH measurements be performed after a prolonged deceleration? An experimental study in a fetal sheep model. Eur J Obstet Gynecol Reprod Biol 2018; 226:54-58. [PMID: 29843068 DOI: 10.1016/j.ejogrb.2018.05.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 05/21/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of fetal heart rate monitoring during labour is to identify and prevent foetal distress, but its evaluation is not perfect. Fetal scalp blood sampling for pH measurement is one of the second-line methods of monitoring when fetal heart rate is classified as suspicious. This study aims to determine when pH testing should be performed after a prolonged deceleration. STUDY DESIGN This was an experimental study in a fetal sheep model. A partial umbilical cord occlusion was performed for seven minutes followed by a recuperation period of 30 min. Hemodynamic parameters (heart rate, mean blood pressure and intra-amniotic pressure) and blood gases were recorded before occlusion (T0), during occlusion (T4), just after the end of occlusion (T7), and then 10, 20 and 30 min after occlusion (T17, T27 and T37 respectively). RESULTS Ten experiments were carried out. During partial cord occlusion, the fetal pH decreased significantly to acidosis. After a prolonged deceleration with fetal acidosis, the pH recovered to a normal value, defined by a pH greater than or equal to 7.25, after 20 min of recuperation. CONCLUSION After a prolonged deceleration, fetal pH normalizes between 20 and 30 min thereafter. Thus, if a foetal blood sample is indicated, this delay must be respected in order to avoid inducing an unnecessary intervention decision.
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Affiliation(s)
- H Dupuis
- Univ. Lille, EA 4489, Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France.
| | - L Ghesquière
- Univ. Lille, EA 4489, Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France
| | - Julien De Jonckheere
- Univ. Lille, EA 4489, Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, CIC-IT 1403, MRRC, F-59000 Lille, France
| | - E Aubry
- Univ. Lille, EA 4489, Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Pediatric Surgery, F-59000 Lille, France
| | - D Sharma
- Univ. Lille, EA 4489, Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Pediatric Surgery, F-59000 Lille, France
| | - P Deruelle
- Univ. Lille, EA 4489, Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France
| | - L Storme
- Univ. Lille, EA 4489, Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Neonatology, F-59000 Lille, France
| | - V Houfflin-Debarge
- Univ. Lille, EA 4489, Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France
| | - C Garabedian
- Univ. Lille, EA 4489, Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France
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Khashana A, Ahmed E. Hyperdehydroepiandrosterone in neonates with hypoxic ischemic encephalopathy and circulatory collapse. Pediatr Neonatol 2017; 58:504-508. [PMID: 28462900 DOI: 10.1016/j.pedneo.2016.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 04/21/2016] [Accepted: 09/29/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Circulatory collapse is a very common complication of the critical illnesses in neonates including neonates with hypoxic ischemic encephalopathy; it can be the end result and cause of death of several conditions. Often, despite treatment with fluid resuscitation and vasopressor agents, circulatory collapse persist, and blood pressure can remain critically low, compromising adequate blood flow to vital organs and brain. Low blood pressure has been associated with increased mortality. METHOD To investigate adrenal function in newborn infants who suffer from circulatory collapse during hypoxic ischemic encephalopathy. A total of 30 infants were analyzed in the study: 15 neonates in group A (neonates had hypoxic ischemic encephalopathy with vasopressor resistant hypotension) and 15 neonates in group B (neonates with hypoxic ischemic encephalopathy without vasopressor resistant hypotension). All the studied patients were subjected to history, examinations and laboratory investigation including serum cortisol concentrations and cortisol precursor's levels. RESULTS The cortisol concentrations did not differ significantly between the two groups: (12.9 ± 4.3) μg/dL and (12.1 ± 2.4) μg/dL in group A and group B, respectively. There are highly significant differences between groups A and B regarding Dehydroepiandrosterone (342.1 ± 101.3) μg/dL, (33.4 ± 16.5) μg/dL, respectively. CONCLUSION In this study, we noticed that cortisol concentrations did not differ between both groups in contrast to the expectation that neonates with critical illnesses should have higher cortisol concentrations than normal neonates. However, the marked increase in dehydroepiandrosterone DHEA may cause decrease cortisol function, so those neonates having accumulation of dehydroepiandrosterone may suffer from manifestation of adrenal insufficiency and vasopressor resistant hypotension in spite of normal cortisol level.
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Affiliation(s)
- Abdelmoneim Khashana
- PEDEGO Research Center, Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Pediatrics and Neonatology, Suez Canal University Hospital, Ismailia, Egypt.
| | - Engy Ahmed
- Epidemiology and Statistics, Health authority, Ismailia, Egypt
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Brown AK, Greisen G, Haugsted U, Jonsbo F. Formal training in general movement assessment is required to effectively evaluate infants with perinatal asphyxia in outpatient settings. Acta Paediatr 2016; 105:1056-60. [PMID: 27240948 DOI: 10.1111/apa.13491] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 04/21/2016] [Accepted: 05/30/2016] [Indexed: 11/28/2022]
Abstract
AIM General movement assessment (GMA) can help to identify children with a high risk of developing neurological dysfunction, such as cerebral palsy, and certified training is provided in this specialism. The aim of this study was to investigate the feasibility and reliability of using video recordings to assess GMA, in a busy Danish outpatient clinic. METHODS The study comprised 30-term infants born with perinatal asphyxia, who were video recorded at three months. They were assessed by two certified GMA observers and re-assessed two weeks later. Interobserver and intra-observer agreements were analysed using proportional agreement, and nominal kappa statistics were used to calculate 95% confidence intervals (95% CI). RESULTS We found substantial and almost perfect interobserver and intra-observer reliability. Intra-observer agreement was 0.85 (95% CI: 0.65-1.00; p < 0.0001) and 0.85 (95% CI: 0.62-1.00; p < 0.0001), and interobserver agreement was 0.71 (95% CI: 0.45-0.96; p < 0.0001) at time point one and 0.85 (95% CI: 0.63-1.00; p < 0.0001) two weeks later. All video recordings were completed within our multidisciplinary outpatient clinic without delay. CONCLUSION This study demonstrated the reliability of the GMA method in a busy multidisciplinary Danish paediatric outpatient setting, when assessors had been formally trained in the method and used it regularly.
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Affiliation(s)
- Annemette K. Brown
- Department of Physiotherapy and Neurology; Nordsjaelland University Hospital; Hilleroed Denmark
- Department of Children and Adolescence; Nordsjaelland University Hospital; Hilleroed Denmark
| | - Gorm Greisen
- Department of Neonatalogy; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - Ulla Haugsted
- Department of Occupational Therapy and Physiotherapy; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - Finn Jonsbo
- Department of Children and Adolescence; Nordsjaelland University Hospital; Hilleroed Denmark
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Bouiller JP, Dreyfus M, Mortamet G, Guillois B, Benoist G. [Intrapartum asphyxia: Risk factors and short-term consequences]. ACTA ACUST UNITED AC 2015; 45:626-32. [PMID: 26321609 DOI: 10.1016/j.jgyn.2015.06.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 05/31/2015] [Accepted: 06/09/2015] [Indexed: 11/29/2022]
Abstract
UNLABELLED Intrapartum asphyxia is a rare yet serious complication during labor with immediate consequences and possible long-term neurological impairment. The international Cerebral Palsy Task Force established criteria that attribute a cerebral palsy to intrapartum asphyxia: metabolic acidemia measured at birth with pH<7 and base deficit≥12mmol/L. OBJECTIVE To determine the risk factors of an intrapartum asphyxia occurring in term live births, to evaluate the short-term consequences. METHODS Our retrospective study included all births between 2002 and 2010 in a level 3 maternity of a university hospital center. Inclusion criteria were those of the Cerebral Palsy Task Force associated with a gestational age≥34weeks of gestation. We studied the conventional markers of intrapartum asphyxia: Apgar score at 5minutes, abnormal cardiotogographic recordings whether they occurred after a sentinel hypoxic event or not before and during labor. The duration of expulsive efforts, the amniotic fluid aspects, the delivery mode as well as the preexisting pregnancy pathologies were also evaluated. On the other hand, we studied the short-term consequences at the newborns: death, multiorgan failure and especially the occurring of a neonatal encephalopathy using Sarnat and Sarnat staging. RESULTS One hundred and twenty-nine newborns (0.43%) out of 29,416 live births had a pH<7 of whom only 82 (0.27%) presented a real intrapartum asphyxia and were included in this study. A preexisting pregnancy pathology was found in 22% of the women. Hypoxic events were noted in only 9/82 of the cases. Abnormal cardiotocographic recordings were present in 97.6% of the cases. The duration of expulsive efforts as well as the amniotic fluid aspects did not interfere with the occurring of a metabolic acidemia. Caesarean rate was at 46.3% and instrumental extraction rate was at 34.1%. Thity-eight newborns (46.3%) were admitted in neonatal intensive care in which we noted 3 deaths (3.65%), 2 multiorgan failures (2.4%) and 17 neonatal encephalopathy (20.7%). The pH value seemed to influence the occurring of an encephalopathy: 50% when pH<6.9 vs. 13.6% when pH≥6.9 (P=0.0013), as well as for the base deficit: 50% when BD<-18 vs. 15.7% when BD≥-18 (P=0.0068). Apgar score at 5minutes also seemed predictive for a neonatal encephalopathy: 100% when<4, 46% between 4 and 6 and 11% when>6 (P<0.001). CONCLUSIONS Our results showed an intrapartum asphyxia rate half the one widely recorded of 0.5% of total live births. Our study also validates the commonly used markers to evaluate a high risk of an early neonatal encephalopathy. This study should be continued with the evaluation of hypoxia long-term consequences on the psychomotor development of these kids and especially the occurring of cerebral palsy.
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Affiliation(s)
- J-P Bouiller
- Département d'obstétrique, gynécologie et médecine de la reproduction, CHU de Caen, Caen 14000, France; UFR de médecine, université de Caen Basse-Normandie, esplanade de la Paix, 14032 Caen cedex 5, France.
| | - M Dreyfus
- Département d'obstétrique, gynécologie et médecine de la reproduction, CHU de Caen, Caen 14000, France; UFR de médecine, université de Caen Basse-Normandie, esplanade de la Paix, 14032 Caen cedex 5, France
| | - G Mortamet
- Département de néonatologie, CHU de Caen, Caen 14000, France
| | - B Guillois
- UFR de médecine, université de Caen Basse-Normandie, esplanade de la Paix, 14032 Caen cedex 5, France; Département de néonatologie, CHU de Caen, Caen 14000, France
| | - G Benoist
- Département d'obstétrique, gynécologie et médecine de la reproduction, CHU de Caen, Caen 14000, France; UFR de médecine, université de Caen Basse-Normandie, esplanade de la Paix, 14032 Caen cedex 5, France
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Combier E, Charreire H, Le Vaillant M, Michaut F, Ferdynus C, Amat-Roze JM, Gouyon JB, Quantin C, Zeitlin J. Perinatal health inequalities and accessibility of maternity services in a rural French region: closing maternity units in Burgundy. Health Place 2013; 24:225-33. [PMID: 24177417 DOI: 10.1016/j.healthplace.2013.09.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 06/01/2013] [Accepted: 09/18/2013] [Indexed: 11/19/2022]
Abstract
Maternity unit closures in France have increased travel time for pregnant women in rural areas. We assessed the impact of travel time to the closest unit on perinatal outcomes and care in Burgundy using multilevel analyses of data on deliveries from 2000 to 2009. A travel time of 30min or more increased risks of fetal heart rate anomalies, meconium-stained amniotic fluid, out-of-hospital births, and pregnancy hospitalizations; a positive but non-significant gradient existed between travel time and perinatal mortality. The effects of long travel distances on perinatal outcomes and care should be factored into closure decisions.
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Affiliation(s)
- Evelyne Combier
- Centre d'épidémiologie et de santé publique Bourgogne (EA4184). Faculté de Médecine, Dijon, France.
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9
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Validation des gazométries au cordon ombilical : étude au sein d’une maternité française. ACTA ACUST UNITED AC 2012; 40:566-71. [DOI: 10.1016/j.gyobfe.2012.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Indexed: 11/20/2022]
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10
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B-type natriuretic peptide in the recognition of critical congenital heart disease in the newborn infant. Pediatr Emerg Care 2012; 28:735-8. [PMID: 22858747 DOI: 10.1097/pec.0b013e3182624a12] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Infants with congenital heart disease having obstruction to the left ventricular outflow and ductal-dependent systemic circulation can present critically ill with shock. Prompt disease recognition and initiation of prostaglandins are necessary to prevent excess morbidity and mortality. We assessed a large cohort of newborn infants with ductal-dependent systemic circulation to determine if B-type natriuretic peptide (BNP) is consistently elevated at presentation, potentially aiding in diagnosis and treatment. METHODS The clinical records of infants with left-sided obstructive lesions admitted from January 2005 to June 2009 were reviewed. Infants were divided into 2 groups: group 1 was diagnosed with cardiogenic/circulatory shock at presentation, and group 2 consisted of infants with ductal-dependent systemic circulation without evidence of shock. B-type natriuretic peptide levels and other variables between the groups were compared. RESULTS All patients with critical congenital heart disease presenting with shock had elevated BNP levels, ranging from 553 to greater than 5000 pg/mL. Infants in group 1 (shock, n = 36) had significantly higher median BNP levels of 4100 pg/mL at presentation compared with group 2 patients (no shock, n = 86), who had a median BNP of 656 pg/mL (range, 30-3930 pg/mL; P < 0.001). Every 100 U of increase in BNP at presentation increased the likelihood of shock (odds ratio, 100; P < 0.001). CONCLUSIONS B-type natriuretic peptide is markedly elevated in neonates presenting in shock secondary to left-sided obstructive heart disease and is an important diagnostic tool to aid in the rapid identification and treatment of these patients.
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Boog G. [Cerebral palsy and perinatal asphyxia (II--Medicolegal implications and prevention)]. ACTA ACUST UNITED AC 2011; 39:146-73. [PMID: 21354846 DOI: 10.1016/j.gyobfe.2011.01.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 01/18/2011] [Indexed: 01/18/2023]
Abstract
Obstetric litigation is a growing problem in developed countries and its escalating cost together with increasing medical insurance premiums is a major concern for maternity service providers, leading to obstetric practice cessation by many practitioners. Fifty-four to 74 % of claims are based on cardiotocographic (CTG) abnormalities and their interpretation followed by inappropriate or delayed reactions. A critical analysis is performed about the nine criteria identified by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics in their task force on Neonatal Encephalopathy and Cerebral Palsy: four essential criteria defining neonatal asphyxia and five other suggesting an acute intrapartum event sufficient to cause cerebral palsy in term newborns. The importance of placental histologic examination is emphasized in order to confirm sudden catastrophic events occurring before or during labor or to detect occult thrombotic processes affecting the fetal circulation, patterns of decreased placenta reserve and adaptative responses to chronic hypoxia. It may also exclude intrapartum hypoxia by revealing some histologic patterns typical of acute chorioamnionitis and fetal inflammatory response or compatible with metabolic diseases. Magnetic resonance imaging (MRI) of the infant's damaged brain is very contributive to elucidate the mechanism and timing of asphyxia in conjunction with the clinical picture, by locating cerebral injuries predominantly in white or grey matter. Intrapartum asphyxia is sometimes preventable by delivering weak fetuses by cesarean sections before birth, by avoiding some "sentinel" events, and essentially by responding appropriately to CTG anomalies and performing an efficient neonatal resuscitation. During litigation procedures, it is necessary to have access to a readable CTG, a well-documented partogram, a complete analysis of umbilical cord gases, a placental pathology and an extensive clinical work-up of the newborn infant including cerebral MRI. Malpractice litigation in obstetric care can be reduced by permanent CTG education, respect of national CTG guidelines, use of adjuncts such as fetal blood sampling for pH or lactates, regular review of adverse events in Clinical Risk Management (CRM) groups and periodic audits about low arterial cord pH in newborns, admission to neonatal unit, the need for assisted ventilation and the decision-to-delivery interval for emergency operative deliveries. Considering the fast occurrence of fetal cerebral hypoxic injuries, and thus despite an adequate management, many intrapartum asphyxias will not be preventable. Conversely, well-documented hypoxic-ischemic brain insults during the antenatal period do not automatically exclude intrapartum suboptimal obstetric care.
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Affiliation(s)
- G Boog
- Service de gynécologie-obstétrique, hôpital Mère-et-Enfant, CHU de Nantes, 38 boulevard Jean-Monnet, Nantes cedex 1, France.
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Neuroprotection par hypothermie contrôlée dans l’encéphalopathie hypoxique-ischémique du nouveau-né à terme. Arch Pediatr 2010; 17 Suppl 3:S67-77. [DOI: 10.1016/s0929-693x(10)70904-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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