Education in developing countries and reducing maternal mortality: a forgotten piece of the puzzle?

Despite substantial improvement in reducing maternal mortality during the recent decades, we constantly face tragic fact that maternal mortality (especially preventable deaths) is still unacceptably too high, particularly in the developing countries, where 99% of all maternal deaths worldwide occur. Poverty, lack of proper statistics, gender inequality, beliefs and corruption-associated poor governmental policies are just few of the reasons why decline in maternal mortality has not been as sharp as it was wished and expected. Education has not yet been fully recognized as the way out of poverty, improvement of women's role in the society and consequent better perinatal care and consequent lower maternal mortality. Education should be improved on all levels including girls, women and their partners, medical providers, religious and governmental authorities. Teaching the teachers should be also an essential part of global strategy to lower maternal mortality. This paper is mostly a commentary, not a systematic review nor a meta-analysis with the aim to rise attention (again) to the role of different aspects of education in lowering maternal mortality. The International Academy of Perinatal Medicine should play a crucial role in pushing the efforts on this issue as the influential instance that promotes reflection and dialog in perinatal medicine, especially in aspects such as bioethics, the appropriate use of technological advances, and the sociological and humanistic dimensions of this specific problem of huge magnitude. The five concrete steps to achieve these goals are listed and discussed.

Fetal Growth Restriction Before and After Birth

Fetal growth restriction, previously called intrauterine growth restriction, is a condition in which a fetus does not achieve its full growth potential during pregnancy. Early detection and management of fetal growth restriction are essential because it has significant clinical implications in childhood. It is diagnosed by estimated fetal weight or abdominal circumference below the 10th percentile on formal ultrasonography. Early-onset fetal growth restriction is diagnosed before 32 weeks' gestation and has a higher risk of adverse fetal outcomes. There are no evidence-based measures for preventing fetal growth restriction; however, aspirin used for the prevention of preeclampsia in high-risk pregnancies may reduce the likelihood of developing it. Timing of delivery for pregnancies affected by growth restriction must be adjusted based on the risks of premature birth and ongoing gestation, and it is best determined in consultation with maternal-fetal medicine specialists. Neonates affected by fetal growth restriction are at risk of feeding difficulties, glucose instability, temperature instability, and jaundice. As these children age, they are at risk of abnormal growth patterns, as well as later cardiac, metabolic, neurodevelopmental, reproductive, and psychiatric disorders.

Prenatal diagnosis and planned peripartum care improve perinatal outcome of fetuses with transposition of the great arteries and intact ventricular septum in low-resource settings

OBJECTIVE

To report on the feasibility of establishing a regional prenatal referral network for critical congenital heart defects (CHDs) and its impact on perinatal outcome of fetuses with transposition of the great arteries and intact ventricular septum (TGA-IVS) in low-resource settings.

METHODS

This was a retrospective study of consecutive fetuses with a diagnosis of TGA-IVS between January 2011 and December 2019 in Kochi, Kerala, India. A regional network for prenatal diagnosis and referral of patients with critical CHDs was initiated in 2011. Pregnancy and early neonatal outcomes were reported. The impact of the timing of diagnosis (prenatal or after birth) on age at surgery, perinatal mortality and postoperative recovery was evaluated.

RESULTS

A total of 82 fetuses with TGA-IVS were included. Diagnosis typically occurred later on in gestation, at a median of 25 (interquartile range (IQR), 21-32) weeks. The majority (78.0%) of affected pregnancies resulted in live birth, most (84.4%) of which occurred in a specialist pediatric cardiac centers. Delivery in a specialist center, compared with delivery in a local maternity center, was associated with a significantly higher rate of surgical correction (98.1% vs 70.0%; P = 0.01) and overall lower neonatal mortality (3.7% vs 50%; P = 0.001). The proportion of cases undergoing arterial switch operation after prenatal diagnosis of TGA-IVS increased significantly, along with the prenatal detection rate, over the study period (2011-2015, 11.1% vs 2016-2019, 29.4%; P = 0.001). Median age at surgery was significantly lower in the prenatally diagnosed group than that in the postnatally diagnosed group (4 days (IQR, 1-23 days) vs 10 days (IQR, 1-91 days); P < 0.001). There was no significant difference in postoperative mortality (2.0% vs 3.6%; P = 0.49) between the two groups.

CONCLUSIONS

This study demonstrates the feasibility of creating a network for prenatal diagnosis and referral of patients with critical CHDs, such as TGA, in low-resource settings, that enables planned peripartum care in specialist pediatric cardiac centers and improved neonatal survival. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Perinatal Depression in Low-Income Women: A Literature Review and Innovative Screening Approach

PURPOSE OF REVIEW

This paper reviews literature on perinatal depression prevalence, consequences, and screening among low-income women and women of color. We introduce the Warm Connections program's innovative perinatal depression screening protocol and explore perinatal depression patterns among WIC participants.

RECENT FINDINGS

Perinatal depression negatively impacts maternal and child outcomes. Research shows mixed findings of perinatal depression prevalence rates among low-income women and women of color. The Warm Connections program supports the ability of WIC staff to administer the EPDS to WIC participants. Perinatal depression rates appeared lower in the Warm Connections program than in studies using less specific perinatal depression screening instruments with similar samples. Future research should continue to explore perinatal depression patterns among low-income women and women of color. Partnering with community-based settings such as WIC provides innovative opportunities to provide screening, referral, and treatment for low income women and women of color.

Identification and Management of Cranial Anomalies in Perinatology

Neonatal skull and head shape anomalies are rare. The most common cranial malformations encountered include craniosynostosis, deformational plagiocephaly, cutis aplasia, and encephalocele. Improved prenatal imaging can diagnose morphologic changes as early as the second trimester. Prenatal identification also provides perinatologists and neonatologists with valuable information that helps to optimize care during and after delivery. Cranial anomalies require a multidisciplinary team approach and occasionally a lifetime of care. Today, care begins with the perinatologist as many cranial anomalies can be identified in utero with recent advances in prenatal testing.

The efficacy of cognitive behavior therapy for the treatment of perinatal anxiety symptoms: A preliminary meta-analysis

Cognitive-behavior therapy (CBT) is considered the psychological treatment of choice for anxiety disorders in the general population. However the efficacy of CBT for anxiety that occurs during the perinatal period, defined as the period from conception to 12 months post birth, is less understood. Perinatal anxiety is a complex and multifaceted problem that can affect both the pregnant women and the unborn child, as well as the wider family unit. The aim of this study was to synthesize the current empirical status of CBT for perinatal anxiety using a meta-analytic approach. Relevant articles were identified through a search of electronic databases through to June 2018. The search terms used include 'anxiety' or 'phobia' AND 'perinatal' or 'pregnan* or 'postnatal' or 'postpartum' AND 'CBT' or 'cognitive behav* therapy'. Randomized and non-randomized studies were included within the meta-analysis. A total of 13 studies met the inclusion criteria and were included in the meta-analysis. The pooled between-group mean effect size was small at post treatment (k = 7; d = 0.49; 95% CI: 0.08-0.91) favoring the CBT treatments (Q₁ = 30.13, p <.001). Heterogeneity was high (I² = 80.09). The pooled within-group mean effect size was large across the treatment groups from pre-treatment to post-treatment when combining all of the studies (i.e., controlled and uncontrolled studies; k = 14; d = 0.90; 95% CI: 0.63-1.17). Heterogeneity was high (I² = 88.55). Some preliminary and exploratory moderator analyses were also conducted to inform potential future research in this field.

Quality Improvement in Perinatal Medicine and Translation of Preterm Birth Research Findings into Clinical Care

Billions of dollars are spent yearly in perinatal medicine on studies designed to improve outcomes for mothers and their neonates. However, implementing research findings is challenging and imperfect. Strategies for implementation must be multifaceted and comprehensive. These implementation challenges extend to, and are often greater in, translational and basic science research. The purpose of this review is to discuss current challenges in the provision of quality perinatal and neonatal medical care, particularly those related to preterm birth, and provide examples of prematurity-related perinatal quality collaborative initiatives. Finally, the authors review considerations in implementing both clinical and translational/basic science prematurity research.

A fetal telecardiology service: patient preference and socio-economic factors

OBJECTIVE

The aims of this study were to evaluate patients' opinions on a fetal cardiology telemedicine service compared with usual outpatient care, the effect of the telemedicine consultation on maternal anxiety and its impact on travel times and time absent from work.

METHODS

Prospective study over 20 months. Eligible patients attended for routine anomaly scan followed by fetal echocardiogram transmitted to the regional centre with live guidance by a fetal cardiologist, followed by parental counselling. All patients were offered a fetal cardiology appointment at the regional centre. Structured questionnaires assessing maternal satisfaction, travel times/days off and anxiety scores completed at time of both fetal echocardiograms.

RESULTS

Sixty-seven patients were recruited and 66 completed the study. Participants expressed very high satisfaction rates with fetal telecardiology, equivalent to face-to-face consultation. The telecardiology appointments were associated with significantly reduced travel times and days off work (p < 0.01). Expectant mothers expressed a clear inclination for a fetal cardiology appointment at the local hospital facilitated by telemedicine (p < 0.01).

CONCLUSIONS

Fetal telecardiology is highly acceptable to patients and is even preferred compared with travelling to a regional centre. There are additional socio-economic benefits that should encourage the development of remote fetal cardiology services.

Dar es Salaam perinatal care study: needs assessment for quality of care

OBJECTIVE

Poor obstetric care in low income countries has been attributed to a wide range of factors. We conducted a perinatal care needs assessment in Dar es Salaam health institutions to assess the factors underlying the present poor perinatal outcome.

METHODS

A cross sectional study was conducted in 2005 in all four public hospitals and all five public health centres purposively selected, and in six dispensaries selected using simple random sampling method. WHO Safe Motherhood needs assessment instruments were used to assess structural, systemic and process needs for quality perinatal care. Health care providers, administrators and clients were interviewed about perinatal care services in their respective health institutions.

RESULTS

The majority (72%) of all deliveries in Dar es Salaam took place in the four available public hospitals. The potential coverage of comprehensive and basic emergency obstetric care (EmOC) services were 360% and 350% of the United Nations minimum recommended health institution categories per 500,000 population respectively. The coverage for health centres and dispensaries based on Tanzanian standards were 20% and 24% respectively. Two of the hospitals did not provide theatre and blood transfusion services for 24 hours per day. Two public health centres did not provide delivery services at all and 83% of the dispensaries had poorly established obstetric services. There was only one public neonatal unit that served as a referral institution for all sick newborns delivered in public health institutions in the region.

CONCLUSION

This paper reveals the state of inadequate infrastructure, equipments and supplies for perinatal care in Dar es Salaam public health institutions. A major investment is needed to establish new public infrastructure for maternal and neonatal care, upgrade and optimize use of the existing ones, and improve supply of essential material resources in order to achieve the Millennium Development Goals set for maternal and child survivals by 2015.

[Question raised by the limits of viability in extremely preterm infants]

Recent advances in perinatology allow to take care routinely of extremely preterm babies. Medical problems as well as ethical questions raised by initiation and withdrawal of intensive care of these infants are discussed here. Successively are considered what population is concerned by the so-called limits of viability, the long-term results of the medical interventions and the ethical questions resulting of them.

Diffuse white matter injury and neurologic outcomes of infants born very preterm in the 1990s

Neurocognitive outcomes of infants born very preterm (less than 32 weeks gestation) remain a major concern in perinatal practice. Very preterm birth rates have increased, with enhanced survival since 1990. As focal brain lesions become less common, diffuse injury to both gray and white matter is now the primary focus for improving neurologic outcomes in survivors. Recent evidence supports preoligodendrocytes as the principal cellular target of diffuse white matter injury due to their susceptibility to hypoxic-ischemic and inflammatory insults. An understanding of their development and vulnerability can inform acute nursing care of very preterm infants.

How useful is 3D and 4D ultrasound in perinatal medicine?

AIM

The purpose of this paper is to review and analyze the published literature on the use of three-dimensional (3DUS) and four-dimensional (4DUS) ultrasound in perinatal medicine.

METHODS

We systematically searched Medline through PubMED (January 2000-January 2006), including EMBASE/Excerpta Medica database as well as the Cochrane Database of Systematic Reviews. The search terms used to identify clinical application of 3DUS and 4DUS studies in perinatal medicine were technical development, special features, and recommendation for fetal imaging, research on 3DUS or 4DUS, and the usage of invasive 3DUS or 4DUS procedures. The reference bibliographies of relevant books were also manually searched for supplementary citations. Inclusion criteria were as follows: (1) studies related to the use of 3DUS or 4DUS in perinatal medicine; (2) full text were available in English; (3) publication format of original scientific articles, case reports, editorials or literature reviews and chapters in the books.

RESULTS

Five hundred and seventy-five articles were identified, and among those, 438 were relevant to this review.

CONCLUSIONS

3DUS and 4DUS provided additional information for the diagnosis of facial anomalies, evaluation of neural tube defects, and skeletal malformations. Additional research is needed to determine the clinical utility of 3DUS and 4DUS for the diagnosis of congenital heart disease, central nervous system (CNS) anomalies and detection of fetal neurodevelopmental impairment assessed by abnormal behavior in high-risk fetuses.

Three-Dimensional Echocardiography

Over the past 3 decades, echocardiography has become a major diagnostic tool in the arsenal of clinical cardiology for real-time imaging of cardiac dynamics. More and more, cardiologists' decisions are based on images created from ultrasound wave reflections. From the time ultrasound imaging technology provided the first insight into the human heart, our diagnostic capabilities have increased exponentially as a result of our growing knowledge and developing technology. One of the most significant developments of the last decades was the introduction of 3-dimensional (3D) imaging and its evolution from slow and labor-intense off-line reconstruction to real-time volumetric imaging. While continuing its meteoric rise instigated by constant technological refinements and continuing increase in computing power, this tool is guaranteed to be integrated in routine clinical practice. The major proven advantage of this technique is the improvement in the accuracy of the echocardiographic evaluation of cardiac chamber volumes, which is achieved by eliminating the need for geometric modeling and the errors caused by foreshortened views. Another benefit of 3D imaging is the realistic and unique comprehensive views of cardiac valves and congenital abnormalities. In addition, 3D imaging is extremely useful in the intraoperative and postoperative settings because it allows immediate feedback on the effectiveness of surgical interventions. In this article, we review the published reports that have provided the scientific basis for the clinical use of 3D ultrasound imaging of the heart and discuss its potential future applications.

[Medical-social aspects of reproductive health in pregnant women with perinatal pathology]

On the basis of epidemiological research the state of health of pregnant women and perinatal outcomes in some regions of Azerbaijan republic were investigated. The analysis of perinatal death rates with revealing cases potentially preventing losses, the reasons and risk factors perinatal pathology rates in regional conditions were carried out. The examination of 200 pregnant women from the group with a high risk factor (in connection to the extragenital pathology burdened by the obstetric gynaecological anamnesis) and 100 pregnant women with late beginning of the obstetric survey was carried out. The program pregraviditary preparations and preventive maintenance of pregnant women in high risk group, complex inspection of fetus condition and fetal-placental systems from early terms gestation was a reserve in decrease perinatal diseases and death rates. In this group of patients who were regularly surveyed during the pregnancy, more favourable outcomes were noted which manifested themselves in lower parameters of the morbidity and mortality rates.

[Sensitivity and predictive value of the Johnson and Toshach method to estimate fetal weight]

INTRODUCTION

Several clinical methods have been used to follow up fetal growth, mainly based in uterine enlargement. Ultrasound (US) is nowadays the main tool to evaluate fetal growth; however, is not widely available. Thus, we decided to evaluate the Johnson and Toshach method (JTM) to predict newborns weight on clinical basis.

OBJECTIVE

to evaluate the sensitivity and positive predictive value of the JTM. We selected 132 women with single term pregnancies whose gestational age was previously confirmed by US, and followed the method described by JTM. At the end of pregnancies by delivery or cesarean section, we compared our estimations with the newborn infant's weight. In order to avoid bias, only women whose pregnancies ended in the following 72 hours were included. All clinical measurements were done by one observer. The sensitivity, specificity and positive predictive value of the JTM were calculated.

RESULTS

We found non-significant difference between the mean of the fetal weight (3,295 g) calculated with the JTM and the mean of the newborn infants weight (3,343 g) (p = NS). The standard deviation was 325 g and the standard error mean was >or=53 g or 16 g/kg (error = 1.6%). In normal weight groups of neonates, the JTM had a sensitivity of 97%, a specificity of 71% and the positive predictive value was 98%. We observed a higher sensitivity in the detection of macrosomy (80%) than of low-weight newborns (33%), but with an inverted specificity of 71.4% vs. 99.2%, respectively.

CONCLUSION

The JTM is a useful clinical technique to estimate fetal weight in the third trimester of gestation that may be applied when US is not available, being more sensitive to detect normal weight than macrosomic or low-weight newborns.

Psychoneuroendocrine processes in human pregnancy influence fetal development and health

Individual differences in psychoneuroendocrine function play an important role in health and disease. Developmental models postulate that these individual differences evolve through a progressive series of dynamic time-, place- and context-dependent interactions between genes and environments in fetal, infant and adult life. The effects of early experience have longer-lasting and more permanent consequences than those later in life. Experimental studies in animals have provided convincing evidence to support a causal role for stress-related psychoneuroendocrine processes in negatively influencing critical developmental and health outcomes over the life span, and have also offered valuable insights into putative physiological mechanisms. However, the generalizability of these findings from animals to humans may be limited by the existence of large inter-species differences in physiology and the developmental time-line. We have initiated a program of research in behavioral perinatology and conducted studies over the past several years to examine the effects of stress-related psychoneuroendocrine processes in human pregnancy on fetal developmental and health outcomes. Our findings support a significant and independent role for maternal prenatal stress in the etiology of prematurity-related outcomes, and suggest that these effects are mediated, in part, by the maternal-placental-fetal neuroendocrine axis, and specifically by placental corticotropin-releasing hormone. Our findings also suggest that the use of a fetal challenge paradigm offers a novel way to quantify fetal neurobehavioral maturity in utero, and that the maternal environment exerts a significant influence on the fetal neurodevelopmental processes related to recognition, memory and habituation. Finally, our findings provide preliminary evidence to support the notion that the influence of prenatal stress and maternal-placental hormones on the developing fetus may persist after birth, as assessed by measures of temperament and behavioral reactivity in the first few years of postnatal life. A description of this body of work is followed by the elucidation of questions for further research and a discussion of implications for life-span development and health.

Preterm premature rupture of membranes: perspectives surrounding controversies in management

Preterm premature rupture of the membranes (PPROM) occurs in approximately 3% of all pregnancies, and accounts for one third of all preterm births. Despite its prevalence, optimal management of PPROM remains largely undefined and lacks conformity. In this article, we review the pathophysiology of PPROM, and summarize the available literature describing various management strategies in an effort to define current controversies in the management of PPROM.

Ethical dilemmas in extreme prematurity: recent answers; more questions

Advances in perinatal care allow survival of more extremely premature infants, but the implementation and continuation of intensive care may itself constitute an ethical dilemma, given the limited chances of intact survival among the patients most at risk. This paper discusses several key issues raised by the options that are under general consideration with reference to births of infants at the threshold of viability, in particular: the implications of making a distinction between extreme prematurity and other general medical situations that may involve decisions on ending support; the concrete nature of the restrictions on therapy in such patients interactions and the need for feedback between parents, medical staff and society.

Postnatal blues: a risk factor for postnatal depression

Postnatal blues have been regarded as brief, benign and without clinical significance. However, several studies have proposed a link between blues and subsequent depression but have methodological problems. We report a prospective, controlled study of postpartum women with severe blues which uses systematically devised and validated instruments for that purpose which tests the hypothesis that severe blues increases the risk of depression in the six months following childbirth. 206 first-time mothers were recruited in late pregnancy. Blues status was defined using the Blues Questionnaire and those with severe blues and their controls who had no blues (matched for age, marital status and social class) were followed for 6 months with postal Edinburgh Postnatal Depression Scale. RDC diagnoses were made following SADS-L interview at the end of the protocol. Backwards stepwise Cox regression analysis found severe blues and past history of depression to be independent predictors each raising the risk by almost 3 times. Depression in those with severe blues onset sooner after delivery and lasted longer. The difference was largely accounted for by major depression. Severe postpartum blues are identified as an independent risk factor for subsequent postpartum depression. Screening and intervention programs could be devised.

Proactive management promotes outcome in extremely preterm infants: a population-based comparison of two perinatal management strategies

OBJECTIVE

There is a need for evidence-based knowledge regarding perinatal management in extreme prematurity. The benefit of a proactive attitude versus a more selective one is controversial. The objective of the present study was to analyze perinatal practices and infant outcome in extreme prematurity in relation to different management policies in the North (proactive) and South of Sweden.

METHODS

A population-based, retrospective, cohort study design was used. Data in the Swedish Medical Birth Register (MBR) from 1985 to 1999 were analyzed according to region of birth and gestational age (22 weeks + 0 days to 27 weeks + 6 days). A total of 3 602 live-born infants were included (North = 1040, South = 2562). Survival was defined as being alive at 1 year. Morbidity in survivors, based on discharge diagnoses of major morbidity during the first year of life, was described by linking the MBR to the Hospital Discharge Register.

RESULTS

In infants with a gestational age of 22 to 25 weeks, the proactive policy was significantly associated with 1) increased incidence of live births, 2) higher degree of centralized management, 3) higher frequency of caesarean section, 4) fewer infants with low Apgar score (<4) at 1 and 5 minutes, 5) fewer infants dead within 24 hours, and 6) increased number of infants alive at 1 year. There were no indications of increased morbidity in survivors of the proactive management during the first year of life, and the proportion of survivors without denoted morbidity was larger.

CONCLUSION

In infants with a gestational age of 22 to 25 weeks, a proactive perinatal strategy increases the number of live births and improves the infant's postnatal condition and survival without evidence of increasing morbidity in survivors up to 1 year of age.

The impact of evidence-based education on a perinatal capacity-building initiative in Macedonia

CONTEXT

The perinatal mortality rate (PMR) in Macedonia is among the highest in Europe. The World Bank supported a consultant (HEJ) to collaborate with a Macedonian team to develop a national perinatal strategy with the goal of reducing the PMR. Education was given priority in the form of a hospital-based initiative to develop the capacity of health professionals to introduce evidence-based perinatal practice into 16 participating hospitals. A "train the teachers" approach was used, with trainees introduced to modern education and clinical practice in Sydney and subsequently supported to train their colleagues in Skopje.

OBJECTIVES

To describe the development, implementation and evaluation of the educational intervention.

METHODS

A curriculum, based on specific Macedonian needs, was developed in order to integrate teaching in the knowledge, skills and attitudinal domains of learning, using small group, interactive techniques. Twenty-five Macedonian doctors and nurses participated in 4-month (phase 1a) and 6-month (phase 1b) teaching programmes at a tertiary perinatal unit in Sydney. Australian staff conducted 4 2-week modules for 36 trainees in Macedonia (phase 2). The phase 1 trainees conducted 8 modules for 57 colleagues in Skopje (phase 3). The intervention was evaluated by trainee questionnaires, assessments of competence, changes in hospital practice and pre- (1997-99) and post-intervention (2000-01) comparisons of PMR.

RESULTS

A total of 115 doctors and nurses graduated from the programme. Positive responses to the education programme exceeded 80%. Evidence-based practice in 16 participating hospitals (covering 91% of all Macedonian births) was verified in 6 key areas of neonatology. The PMR fell significantly from 27.4 to 21.5 per 1000 births (RR 0.79, 95% CI 0.73, 0.85). The early neonatal death rate in babies weighing over 1000 g fell by 36%.

CONCLUSIONS

The intervention has increased the capacity of Macedonians to practise best-evidence perinatal medicine and improve outcomes. Sustainability is predicted by the "train the teachers" approach, with concurrent strengthening of the infrastructure and organisational framework.

Effect of administering recombinant erythropoietin to women with postpartum anemia: a meta-analysis

OBJECTIVES

Recombinant erythropoietin (rEpo) has been administered to women with postpartum anemia in an attempt to accelerate their increase in hemoglobin concentration and reduce postpartum transfusions. However, it is not clear whether such an approach can be supported by evidence and should be generally recommended.

STUDY DESIGN AND METHODS

Medical and scientific literature from January 1990 to December 2002 was searched and studies that reported the administration of rEpo to women with postpartum anemia were evaluated.

RESULTS

Eight evaluated studies reported an aggregate of 480 women; 300 rEpo recipients and 180 controls. Significant diversity in design was observed in rEpo dose, route of rEpo administration, iron supplementation, and baseline hemoglobin. No significant safety concerns were reported. In all five studies where it was reported, 4 to 7 days after beginning treatment, greater increases in hemoglobin concentration were observed among the rEpo recipients than among the controls. However, heterogeneity of results (Q-test statistic, p<0.01) indicated that it was not appropriate to apply summary statistics. The effect of rEpo on postpartum transfusion rate was not measurable by summary statistics because of the limited number of transfusions given (no transfusions among the 300 rEpo recipients vs two transfusions among the 180 controls).

CONCLUSION

Administration of rEpo to women with postpartum anemia appears to be safe, and is associated with a trend toward a faster increase in hemoglobin concentration. However, its efficacy in terms of diminishing postpartum transfusions is unproven.

The multiple negative randomized controlled trials in perinatology--why?

Many of the multicenter trials in perinatal medicine have been negative in that they have shown no benefit for the intervention relative to the control. Although a negative trial can improve patient care by the avoidance of an unnecessary treatment, most trials are designed with the intent of the intervention improving outcomes. We selectively reviewed a number of recent trials in order to identify why the trials were negative. In general, the preliminary information on which the trials were based, which was a small trial or a meta-analysis of multiple small trials, was not robust or predictive. The weak preliminary information together with limited numbers of patients, problematic primary outcomes and a poor understanding of the biology of neonatal diseases has limited the ability to reliably design trials with positive outcomes.

[Management of the dead fetus' body during the pre-or perinatal period: fetal pathologist or fetal physician?]

What's about a practitian that have to care a non-existent and still dead patient? What's about a patient that only exists through pictures and pathology? What's about the expectation of the parents and medical team when the questions are mainly restricted to the cause of the death? Responses to these questions represent the aim of this paper that tries to delineate the ambiguity that exists between the facts and their consequences.

Comparison of perinatal health of children born from IVF in Finland in the early and late 1990s

BACKGROUND

The purpose of this study was to investigate whether perinatal health outcomes changed during the 1990s with the increasing use of IVF.

METHODS

Data were from the Finnish Medical Birth Register for periods 1991-1993 and 1998-1999. Outcomes of IVF infants and other infants were compared, both overall and separately for singleton and multiple births, by adjusting for mothers' background variables by logistic regression.

RESULTS

The IVF multiple birth rate, especially the number of triplets, declined from the first (1991-1993) to the second (1998-1999) time-period. The outcomes for IVF newborns improved, especially for multiple births. After adjusting for mothers' background variables, the odds ratios for preterm birth and low birthweight decreased among singletons from 2.2 [95% confidence interval (CI) 1.8-2.8] to 1.8 (CI 1.5-2.1) and from 2.4 (CI 1.9-3.1) to 1.7 (CI 1.4-2.1) respectively and more among multiples from 2.4 (CI 2.0-2.9) to 1.5 (CI 1.2-1.7) and from 1.9 (CI 1.6-2.3) to 1.1 (CI 1.0-1.3) respectively. Still, overall the outcomes for IVF infants remained poorer than those for other infants. A correlation was found between increased use of antenatal services and improved outcomes, but causality cannot be assumed.

CONCLUSION

A trend of improved perinatal health of multiple IVF children was found, mainly due to a decrease in higher order multiple births.

Prenatal and perinatal aspects of a giant fetal cervicothoracal lymphangioma

A massive cervicothoracal lymphangioma was diagnosed in a fetus at 25 weeks of gestation. On ultrasound study, the mass showed septated, cystic components and extended from the right submandibular region to the right anterolateral thoracic wall including the right axilla and right scapula. Close sonographic follow-up revealed an increase in the size of the lymphangioma without fetal hydrops. An interdisciplinary approach including a pediatric surgeon, neonatologist, perinatologist and anesthesiologist was chosen. Elective cesarean section under general anesthesia was planned at 37 + 0 weeks of gestation. Surgical correction of the lymphangioma was successfully performed on the 4th day of life. Possible differential diagnoses and the obstetrical management are presented.

Comparison of management strategies for extreme prematurity in New Jersey and the Netherlands: outcomes and resource expenditure

OBJECTIVE

To quantify differences in resource expenditure in the perinatal period and long-term outcome of extremely premature infants who received systematically different approaches to neonatal intensive care.

METHODS

Perinatal management, mortality, prevalence of disabling cerebral palsy (DCP), and resource expenditure of 2 population-based inception cohorts of extremely premature infants born in the mid-1980s were compared. Electronic fetal monitoring, tocolysis, cesarean section delivery, and assisted ventilation were used to characterize management approaches. Participants included all live births at 23 to 26 weeks' gestation in a 3-county area of central New Jersey (NJ) from 1984 to 1987 (N = 146) and throughout the Netherlands (NETH) in 1983 (N = 142). Mortality and the prevalence of DCP were the primary outcomes. Numbers of hospital days with and without assisted ventilation were the measures of resource expenditure.

RESULTS

Electronic fetal monitoring (100% vs 38%), cesarean section (28% vs 6%), and assisted ventilation (95% vs 64%) were all more commonly used in NJ than in NETH. Ten percent of NJ deaths occurred without assisted ventilation, compared with 45% of Dutch deaths. A total of 1820 ventilator days were expended per 100 live births in NJ, compared with 448 in NETH. The increase in the number of nonventilator days (3174 vs 2265 days per 100 live births) did not reach statistical significance. Survival to age 2 (46 vs 22%) and the prevalence of DCP among survivors (17.2 vs 3.4%) were significantly greater in NJ at age 2 than in NETH at age 5.

CONCLUSIONS

Near universal initiation of intensive care in NJ, compared with selective initiation of intensive care in NETH, was associated with 24.1 additional survivors per 100 live births, 7.2 additional cases of DCP per 100 live births, and a cost of 1372 additional ventilator days per 100 live births.

Defining the relationship between obstetricians and maternal-fetal medicine specialists

OBJECTIVE

The purpose of this study was to determine how frequently general obstetricians refer pregnant patients to maternal-fetal medicine specialists in the presence of the clinical indications specified as appropriate for referral or consultation by the 1996 statement of the Society of Perinatal Obstetricians.

STUDY DESIGN

A questionnaire was mailed to 400 randomly selected general obstetricians across the United States. The obstetricians were asked how often they refer their high-risk pregnant patients to maternal-fetal medicine specialists in the presence of (1) a need for diagnostic or therapeutic procedures, (2) medical/surgical disorders, (3) healthy gravid women with high-risk fetuses, and (4) conditions that necessitate admission for reasons other than delivery. Response categories for each individual procedure/high-risk condition included "always," "frequently," "infrequently," "never," and "not applicable."

RESULTS

Overall, 55% of the responses indicated referral (always or frequently) to maternal-fetal medicine specialists for procedures or in the presence of high-risk conditions. More than 75% of the obstetricians always or frequently refer to maternal-fetal medicine specialists for most diagnostic/therapeutic procedures and for the following high-risk conditions: acute fatty liver, portal hypertension, pulmonary hypertension, transplantations, fetal hydrops, fetal anomaly/cytogenetic abnormality, fetal supraventricular tachycardia or congenital heart block, isoimmunization, and twin-to-twin transfusion syndrome.

CONCLUSION

Most of the conditions for which >75% of the obstetricians refer to maternal-fetal medicine are rarely seen in practice. Comprehensive ultrasound examination is the only commonly encountered clinical situation that >75% of the general obstetricians refer to maternal-fetal medicine specialists.

Philosophy behind science. Confirming affectivity, the dawn of human life: the pre-, peri- and postnatal affective-confirming. Haptonomic accompaniment of parents and their child

This article gives a short introduction to the science of Haptonomy and more specially to the application of its specific phenomenality of psychotactile affective contact and interaction during prenatal and postnatal life and during childbirth. The neurophysiological implications and the influence of this approach on the pain threshold are briefly mentioned, as well as psychological influences on the postnatal development of the child. Finally, there is a critical commentary on the use of the ultra-sound scan.

Obstetrician-gynecologists performing genetic amniocentesis may be misleading themselves and their patients

OBJECTIVE

Our purpose was to compare midtrimester amniocentesis-related fetal loss rates between obstetrician-gynecologists and perinatologists.

STUDY DESIGN

This cohort study analyzes 1384 midtrimester amniocenteses from January 1, 1996, to December 31, 1999. Obstetrician-gynecologists who split their practices between two or more hospitals and explained fetal losses (eg, fetal anomalies, aneuploidy) were excluded from analysis. Eight obstetrician-gynecologists performed 138 procedures; 3 perinatologists performed 1246 procedures. Three experienced obstetrician-gynecologists accounted for 113 procedures. Analysis was by chi2.

RESULTS

Within 30 days of midtrimester amniocentesis, there were 3 fetal losses for obstetrician-gynecologists and 4 for perinatologists (P =.02, chi2 = 5.19, degrees of freedom = 1). Obstetrician-gynecologist loss rates were 1 in 46 procedures versus 1 in 312 procedures for perinatologists. Losses were clustered among the 3 experienced obstetrician-gynecologists (P <.01, chi2 = 6.93, degrees of freedom = 1). The experienced obstetrician-gynecologist fetal loss rate was 1 in 38 amniocenteses, and the perinatologist fetal loss rate was 1 in 312.

CONCLUSION

The risk of fetal loss from midtrimester amniocentesis appears to be higher when performed by an obstetrician-gynecologist compared with a perinatologist.

Antenatal transfer of rural women to perinatal centres. High Risk Obstetric and Perinatal Advisory Working Group

The aim of this study was to describe antenatal transfers of rural women to perinatal centres, and among transferred women, to assess the use of selected evidence-based therapies and determine the predictors of preterm and imminent births. The clinical records of rural women antenatally transferred to perinatal centres in NSW and the ACT during 1997-1998 were reviewed. Of 453 rural antenatal transfers, 408 (90%) were emergency transfers. Increasing remoteness was associated with increased rates of antenatal transfer but not with a lower probability of giving birth. Of all transferred women, 64% delivered; 58% of preterm transfers delivered preterm and of those delivering preterm, 76% delivered within 7 days. Although the main reason for antenatal transfer was the possibility of preterm birth, women presenting with preterm contractions only were less likely to deliver preterm (OR = 0.2, 95% CI 0.1-0.4) or < or = 7 days (OR = 0.3, 95% CI 0.2-0.5) than women with any other presenting symptoms. The overall usage of effective interventions (antenatal steroids, antibiotics for PPROM and beta-mimetic tocolysis to delay birth) among antenatally transferred rural women was high, but there is room for increased uptake prior to transfer.

Thirty years of fetal and neonatal physiologic measurements. Have they made a difference?

In looking at fetal and neonatal measurement technology as covered in this issue and as reported in areas not covered in this issue, we need to ask the question: Has this technology made a difference? Unfortunately, the answer is not clear. There are cases where the answer is a solid "yes" and other cases where "maybe" is the best we can say at the present time. There are also a few examples where even though noble attempts have been made, the answer must be "no." What does this mean in terms of what needs to be done? We certainly need to continue the development of new measurement technology and to carry out this development based on sound physiologic and engineering principles. We need to understand better the physical and biologic basis of the measurements that we make and to perform carefully controlled clinical trials of technology before bringing it to the marketplace. Data presentation and archiving is an important issue that, although it is being addressed today, still has future implications as the amount of data increase. Finally, we must not forget the importance of our ultimate goal of helping families to have healthy, happy offspring.

Intrapartum drainage of fetal pleural effusion

Our objective was to describe our experience with intrapartum thoracocentesis in fetuses with severe bilateral pleural effusion. We describe the outcome of four consecutive cases of fetal pleural effusion due to chylothorax that were managed by intrapartum thoracocentesis. These fetuses were not candidates for pleuro-amniotic shunting either because of the need for prompt delivery (three fetuses) or because of advanced gestational age (one fetus). Thoracocentesis was performed in the operating theatre under ultrasound guidance prior to Caesarean delivery. Gestational age at the time of diagnosis and thoracocentesis ranged between 26-34 weeks and 31-34 weeks respectively. Bilateral thoracocentesis was performed in two fetuses and unilateral in the remaining two fetuses. All four infants were born in a relatively good condition; however, all eventually required intubation, ventilation and chest tubes. Chest tubes were introduced between 2 h and 5 days after delivery in three infants, and immediately after birth in one infant who was hydropic. Two infants survived and are developing normally. One infant died from sepsis following successful pleurodesis and one from aspiration on day 51. Our conclusions are that intrapartum thoracocentesis seems to be a relatively simple procedure, that allows newborns with pleural effusion, to breathe spontaneously or be more easily ventilated. This in turn, reduces the need to introduce chest tubes in an emergency situation.

Evidence-based medicine

Evidence-based medicine, whose philosophical origins extend back to mid-19th century Paris and earlier, is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that we individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatment and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer. Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best external evidence, practice risks becoming rapidly out of date, to the detriment of patients. The practice of evidence-based medicine is a process of life-long, self-directed learning in which caring for our own patients creates the need for clinically important information about diagnosis, prognosis, therapy, and other clinical and health care issues, and in which we (1) convert these information needs into answerable questions; (2) track down, with maximum efficiency, the best evidence with which to answer them (whether from the clinical examination, the diagnostic laboratory from research evidence, or other sources); (3) critically appraise that evidence for its validity (closeness to the truth) and usefulness (clinical applicability); (4) integrate this appraisal with our clinical expertise and apply it in practice; and (5) evaluate our performance.