Report of a consensus conference on transplant program quality and surveillance

Public reports of organ transplant program outcomes by the US Scientific Registry of Transplant Recipients have been both groundbreaking and controversial. The reports are used by regulatory agencies, private insurance providers, transplant centers and patients. Failure to adequately adjust outcomes for risk may cause programs to avoid performing transplants involving suitable but high-risk candidates and donors. At a consensus conference of stakeholders held February 13-15, 2012, the participants recommended that program-specific reports be better designed to address the needs of all users. Additional comorbidity variables should be collected, but innovation should also be protected by excluding patients who are in approved protocols from statistical models that identify underperforming centers. The potential benefits of hierarchical and mixed-effects statistical methods should be studied. Transplant centers should be provided with tools to facilitate quality assessment and performance improvement. Additional statistical methods to assess outcomes at small-volume transplant programs should be developed. More data on waiting list risk and outcomes should be provided. Monitoring and reporting of short-term living donor outcomes should be enhanced. Overall, there was broad consensus that substantial improvement in reporting outcomes of transplant programs in the United States could and should be made in a cost-effective manner.

Delivery after caesarean section: consultant obstetricians' professional advice and personal preferences

The objective of this study was to determine how obstetricians would wish to be managed in their own pregnancy and their advice to patients delivering after a caesarean section. A questionnaire was sent to 219 consultant obstetricians in two large UK medical deaneries investigating their personal preferences for delivery and management of spontaneous, augmented and induced labour after a caesarean section and how they advise their patients related to the indication for the previous caesarean section. Responses were analysed according to age and gender. The questionnaire yielded a 68% response rate. None would counsel against labour unless there were contraindications. The majority would recommend labour for all indications for the previous caesarean section, although personal preferences were lower (p<0.04): 56% would recommend labour to their patients after a failed instrumental delivery, but only 36% would personally choose that option (p<0.002). Female obstetricians would contemplate and recommend labour more readily than males. Labour augmentation and induction was more frequently recommended (66% and 57%, respectively) than opted for personally (57% and 52%). Reluctance for labour augmentation and induction was greatest among younger consultants. While the majority of consultants favour labour for themselves and recommend this for their patients, it was reassuring to note that patients are encouraged to make the final decision. Informed patient choice is paramount and it is therefore important that full information about risks and benefits is available.

Antenatal screening for Down's syndrome using the Integrated test at two London hospitals

We carried out an audit of antenatal screening for Down's syndrome using the Integrated test (which provides a single screening result from information collected in the late first and early second trimesters of pregnancy) which was introduced into routine antenatal care at two London hospitals, University College Hospital (UCH) and St Mary's Hospital, in 2003–4. The audit was based on 15,888 women who accepted screening and booked in the first trimester. The Down's syndrome detection rate was 87% (95% confidence interval [CI], 74–95) consistent with an expected detection rate of 89% based on applying the estimates of screening performance of the Serum, Urine and Ultrasound Screening Study (SURUSS) to the maternal age distribution of women who were screened at UCH and St Mary's. The observed false-positive rate was 2.1% (95% CI, 1.9–2.3), compared with an expected of 2.5% for women of the same age. An audit trail (conducted at UCH) indicated that 98% (10,746/10,961) of women accepted integrated screening (2% having a first trimester test) and of these, 94% (10, 116) completed both stages of the test. The audit demonstrated that it is feasible to conduct integrated screening within the NHS with a high acceptance rate and a screening performance consistent with that determined from previous research studies.

Increased first-trimester fetal nuchal translucency thickness in association with chondroectodermal dysplasia (Ellis-Van Creveld syndrome)

Increased nuchal translucency thickness (NT) is an established sonographic marker of fetal chromosomal abnormality. Several structural fetal defects and genetic syndromes including a range of skeletal dysplasias have been reported in association with increased NT. We report the first case of fetal Ellis-Van Creveld syndrome presenting as raised fetal NT at 13 weeks' gestation. Ultrasonography at 18 weeks' gestation demonstrated a narrow thorax, marked shortening of the long bones with bowed femora and hexadactyly of hands and feet. Pregnancy was terminated at 23 weeks' gestation. The postmortem radiological examination revealed short and bowed long bones with rounded metaphyses, postaxial polydactyly of hands and feet, short ribs and narrow thorax. The acetabular roofs were horizontal with medial and lateral spurs. This case adds a further type of severe skeletal dysplasia to the list of genetic syndromes which may present as increased fetal NT in the late first trimester.

Congenital absence of portal vein in the fetus: a case report

Congenital absence of portal vein (CAPV) is a rare abnormality, which may be associated with other abnormalities. We report a case of prenatal diagnosis of absent portal vein confirmed on postnatal ultrasonography and computed tomography scan. The ultrasound features of CAPV include dilated intra-abdominal segment of umbilical vein, dilated inferior vena cava and the presence of hyperechogenic areas in the liver. Blood coming from the umbilical vein directly drains into the inferior vena cava. The dilated intra-abdominal segment of the umbilical vein shows high velocity pulsatile flow, resembling that of ductus venosus. These findings should prompt a careful search for the portal vein and any associated anomalies.

Early-onset fetal hydrops and muscle degeneration in siblings due to a novel variant of type IV glycogenosis

We report on 3 consecutive sib fetuses, presenting at 13, 12, and 13 weeks of gestation, respectively, with fetal hydrops, limb contractures, and akinesia. Autopsy of the first fetus showed subcutaneous fluid collections and severe degeneration of skeletal muscle. Histologic studies demonstrated massive accumulation of diastase-resistant periodic acid-Schiff-positive material in the skeletal muscle cells and epidermal keratinocytes of all 3 fetuses. Enzyme studies of fibroblasts from the 3rd fetus showed deficient activity of glycogen brancher enzyme, indicating that this is a new, severe form of glycogenosis type IV with onset in the early second trimester.

Glucose production by the human placenta in vivo

The human placenta transports glucose by facilitated diffusion down a concentration gradient from mother to fetus. It has previously been considered incapable of glucose synthesis. However, recent work has demonstrated the presence in placental tissue of glucose-6-phosphatase, which is required for the final step in the synthesis of glucose. Following continuous intravenous infusion into the maternal circulation of the stable isotope, 6,6-(2)H(2)glucose, during elective caesarean section, we have observed isotope dilution in the umbilical vein, without further dilution in the umbilical artery. Using a mathematical model containing maternal, placental and fetal compartments, the data were compatible with the release of glucose by the placenta. We conclude that the human placenta at term can produce glucose.

The effect of epidural bupivacaine on the fetal electrocardiogram

Fetal electrocardiogram waveform analysis was used to assess the effect of epidural bupivacaine on the fetal myocardial conducting system by evaluating its effect on the PR interval, RR interval, T/QRS ratio and the PR-RR correlation coefficient. There were no significant changes in either the PR interval or the PR-RR correlation coefficient. There was a significant increase in the fetal heart rate and a significant fall in the T/QRS ratio. Epidural bupivacaine does not alter fetal myocardial conduction as measured by the PR interval and it does not induce ischaemic cardiac changes as assessed by the T/QRS ratio.

Assessing the contribution of birth asphyxia to cerebral palsy in term singletons

In a geographically-based study, we investigated the risk of cerebral palsy following intrapartum asphyxia at term, and the contribution of intrapartum asphyxia at term to the overall rate of cerebral palsy. We used stringent criteria for identifying intrapartum asphyxia, while recognising that the initial hypoxial insult might have occurred in the antenatal period. In the first part of the investigation, a cohort of 160 term, singleton infants, with a low (< or = 3) 1-minute Apgar score, was followed to the age of 5 years. Six infants in the cohort had presumed intrapartum asphyxia, of whom two died in the neonatal period, three had spastic quadriparesis, profound developmental delay and visual impairment, and one was unimpaired. The frequency of cerebral palsy associated with birth asphyxia was estimated as one in 3700 full-term livebirths. To assess the impact of birth asphyxia on the overall rate of cerebral palsy, all cases of cerebral palsy born in the study period were identified. Of the 30 cases, the three identified in the follow-up study were the only ones whose impairment could be attributed to birth asphyxia in a full-term birth. Birth asphyxia at term therefore was associated with 10% [95% confidence interval (CI) 2.1, 26.5] of all cases of cerebral palsy and with 20% (95% CI 4.3, 48.1) of the 15 cases of cerebral palsy in children born at term.

Midtrimester chorionic villus sampling: an alternative approach?

OBJECTIVE

Our purpose was to audit midtrimester chorionic villus sampling after a positive maternal serum screening test for autosomal trisomy.

STUDY DESIGN

From January 1990 until July 1993 chorionic villus sampling was offered to all screened positive women.

RESULTS

Five hundred fifty-one mothers had chorionic villus sampling. The mean age was 31.7 years. The mean gestational age was 18.2 weeks. The mean time for direct karyotyping was 4.4 days and for culture results 20.2 days. Results were obtained in 99.6% of samples: direct plus culture results in 94%, direct results alone in 2.3%, and culture results alone in 3.3%. Fourteen pregnancies had abnormal karyotypes. There were five cases of placental mosaicism and one false-positive result. The loss rate was 0.4%.

CONCLUSION

Midtrimester chorionic villus sampling, which is easier to perform than cordocentesis, provides a rapid and reliable karyotype. The complication rate is comparable to that of other invasive procedures.

Clustering of perinatal markers of birth asphyxia and outcome at age five years

OBJECTIVES

In a cohort of term infants with cerebral depression at delivery, to investigate the association of perinatal signs of birth asphyxia, particularly abnormal fetal heart rate patterns in labour, acidaemia, and serious neonatal encephalopathy, with neurodevelopmental outcome at age five years.

DESIGN

Five year follow up study of a birth cohort.

SETTING

Regional maternity hospital.

SUBJECTS

One hundred and eighty-four singleton infants with a 1 min Apgar score < or = 3, born at term between January 1984 and September 1985.

MAIN OUTCOME MEASURES

Neonatal death, cerebral palsy, and scores on a battery of neurodevelopmental tests at age five.

RESULTS

Seven infants had a cluster of perinatal signs suggestive of birth asphyxia; all included serious neonatal encephalopathy. Three of these infants died neonatally, three had spastic quadriparesis with profound developmental delay, and one was unimpaired at the age of five. Among the remaining infants, no association was found between severely abnormal fetal heart rate patterns in labour and scores on neurodevelopmental tests, or between acid-base status at delivery and test scores.

CONCLUSIONS

Birth asphyxia, identified by a cluster of abnormal perinatal signs, including serious neonatal encephalopathy, has a poor prognosis. If serious encephalopathy is not present, cerebral depression at birth preceded by abnormal fetal heart rate patterns in labour, or with acid-base derangement, is not predictive of later impairment.

The contribution of dystocia to the cesarean section rate

OBJECTIVE

Our purpose was to examine the indications for performing cesarean sections in current obstetric practice and to define and measure the true contribution of dystocia ("difficult labor") to the overall cesarean section rate.

STUDY DESIGN

A prospective audit was done of all cesarean sections performed during 1991 at The Queen Mother's Hospital, Glasgow, a teaching hospital and tertiary referral center.

RESULTS

The cesarean section rate for 1991 was 16.3%. Dystocia was the primary indication in 16% of all cesarean sections in 1991 but was actually a contributing factor, directly or indirectly, in the decision to operate in up to 38% of all cesarean sections that year. Seventy-eight percent of patients delivered because of dystocia were in spontaneous labor. We advocate more widespread use of a policy of active management in nulliparous women who labor spontaneously. If dystocia is addressed successfully, then many repeat cesarean sections may also be avoided.

CONCLUSIONS

Improved management of dystocia in nulliparous women, such as the use of a policy of active management of labor, may be the most useful approach to reducing the cesarean section rate in modern obstetric practice.

Fetal catecholamine responses to vibroacoustic stimulation

OBJECTIVE

The aim of this study was to determine whether fetal vibroacoustic stimulation caused a surge of catecholamines from the fetal sympathoadrenal system.

STUDY DESIGN

A randomized, prospective, controlled trial was performed at The Queen Mother's Hospital, Glasgow. Circulating catecholamine levels in cord blood from a group of fetuses who received vibroacoustic stimulation 1 to 2 minutes before delivery by elective cesarean section (n = 25) were compared with those from a group of controls (n = 23) (Mann-Whitney U test). Fetal heart rate response to vibroacoustic stimulation was recorded in 10 additional pregnancies under identical experimental conditions.

RESULTS

No differences were found in norepinephrine or epinephrine levels between the vibroacoustic stimulation group and the control group. A positive fetal heart rate response was observed in seven of 10 fetuses tested. Fetal norepinephrine levels were also found to be influenced by maternal blood pressure and administration of ephedrine.

CONCLUSIONS

Under these conditions vibroacoustic stimulation does evoke the characteristic fetal heart rate response, but it does not induce a surge of catecholamines from the fetal sympathoadrenal system. Therefore it is unlikely that the immediate fetal heart rate response to vibroacoustic stimulation is induced by a surge in systemic catecholamines.

Clinical assessment of fetal electrocardiogram monitoring in labour

OBJECTIVE

To assess the potential clinical value of fetal electrocardiographic (ECG) monitoring in labour.

DESIGN

Descriptive study of the use of ECG waveform analysis during labour and its correlation with other indices of fetal and neonatal well-being.

SETTING

Teaching hospital in Oxford.

SUBJECTS

86 high risk pregnancies.

MAIN OUTCOME MEASURES

Suitability of ST Segment Analyser (Cinventa, Sweden) for clinical use; relation between the T/QRS ratio during labour (an index of ST segment and T wave elevation) and intrapartum cardiotocography, umbilical artery pH at birth and Apgar scores; T/QRS ratio trends in labour.

RESULTS

The system was robust and user-friendly. No statistically significant relation was found between T/QRS ratios in labour and FHR abnormalities in the cardiotocograph. There was a weak relation between T/QRS ratios and umbilical artery acidosis: at a cervical dilatation of 4 cm, the Spearman rank correlation of the mean T/QRS ratio with umbilical artery actual base deficit was r = -0.31, 0.05 greater than P greater than 0.01. The correlation of T/QRS with the umbilical artery pH was not statistically significant, although a trend was present (Spearman rank: r = -0.26, P greater than 0.05). Correlation of the T/QRS ratio with Apgar scores at 1 and at 5 min was not statistically significant. Only 3 of 16 infants with an Apgar score of less than 7 at 1 min had a mean T/QRS ratio above 0.25 at any time during labour.

CONCLUSION

Further research is necessary before a decision can be made whether this new method of fetal monitoring should be introduced into clinical practice.

The prevalence, aetiology and clinical significance of pseudo-sinusoidal fetal heart rate patterns in labour

OBJECTIVE

To investigate the prevalence of sinusoidal and pseudo-sinusoidal fetal heart rate (FHR) patterns in labour and the relation between the characteristics of the FHR pattern and fetal outcome.

DESIGN

A prospective observational study over a 6-month period in which all women who had continuous FHR monitoring in labour had their intrapartum cardiotocographs (CTGs) scrutinized for the presence of sinusoidal or pseudo-sinusoidal FHR patterns.

SETTING

John Radcliffe Hospital, Oxford.

SUBJECTS

1520 women who had fetal monitoring during labour for various reasons.

MAIN OUTCOME MEASURES

Both internal (electrocardiographic) and external (ultrasound) recordings of the FHR were analysed. Abnormal FHR patterns were related to obstetric characteristics and fetal outcome in terms of Apgar scores, umbilical artery pH and admission to the special care unit.

RESULTS

No true sinusoidal FHR patterns were observed, but pseudo-sinusoidal FHR patterns were found in 230 of the 1520 CTGs examined (15%). Of these, 219 were classified as minor (amplitude 5-15 beats/min) and 11 as intermediate (amplitude 16-24 beats/min). Major pseudo-sinusoidal FHR patterns (amplitude greater than 24 beats/min) were not observed. Minor pseudo-sinusoidal FHR patterns had a mean duration of 21 (SD 13) min and typically occurred once or twice early in labour. Using logistic regression analysis a significant, independent relation was demonstrated between the presence of minor pseudo-sinusoidal FHR patterns and the use of pethidine (RR 1.84, 95% CI 1.3 to 2.59, P less than 0.0001) and epidural analgesia (RR 1.85, 95% CI 1.24 to 2.76, P less than 0.001). Intermediate pseudo-sinusoidal FHR patterns were found in association with both in utero fetal sucking and transient episodes of fetal hypoxia such as that caused by periodic umbilical cord compression.

CONCLUSION

Pseudo-sinusoidal FHR patterns in labour will usually be associated with a normal fetal outcome but a careful fetal assessment is mandatory.

How to assess fetal metabolic acidosis from cord samples

The degree of metabolic acidosis at birth has been calculated in cord artery and vein samples from 21 term fetuses with cord artery pH less than 7.20. The aim of the study was to compare base deficit values calculated from either Siggaard-Andersen alignment nomogram (BD blood) or the Acid-Base chart (BD extra cellular fluid, BDecf). BDblood was found to be consistently higher in the cord artery as compared with BDecf, 13.2 +/- 3.5 and 9.9 +/- 2.9 mmol/l (Mean +/- SD), respectively. A significant correlation was found between cord artery PCO2 and BDblood whereas BDecf appeared unaffected by PCO2. In cases with cord entanglement BDecf a-v differences were increased to 3.4 +/- 2.3 mmol/l as compared with the small a-v difference noted in acidotic cases without cord entanglement, 1.1 +/- 1.25 mmol/l. It is speculated that with acutely emerging, intermittent asphyxia due to cord compression, a cord artery and vein difference in metabolic acidosis may exist and where the vein captures the basal level and the artery the acute changes. It is concluded that BDecf in both cord artery and vein add valuable information on the mechanisms behind metabolic acidosis.

Birth asphyxia and the intrapartum cardiotocograph

The intrapartum cardiotocographs (CTGs) of 38 severely asphyxiated, term infants, born during a 17-month period, and those of 120 healthy term infants acting as controls were independently reviewed by three investigators who were unaware of the clinical outcome. Inter-observer agreement was good (Kappa statistic = 0.74, P less than 0.0001). The investigators found that cardiotocographic abnormalities were present in 33 of the asphyxiated infants (87%) and in 35 of the controls (29%) and predicted that the abnormalities were severe enough to lead to significant fetal metabolic acidosis at delivery in 23 asphyxiated infants (61%) and in 11 controls (9%). The differences between the two groups were highly significant (P less than 0.001). Using the traditional diagnostic criteria for fetal distress, the investigators found that fetal blood sampling was indicated in 58% of cases in the asphyxia group and in 20% of controls but was only performed in 16% of asphyxiated infants and in 8% of controls. Furthermore, the median response times of delivery suite staff for abnormal fetal heart rate patterns were similar whether the FHR changes, classified using Krebs' CTG scoring system, were moderate or severe: 80 min and 90 min, respectively. These findings suggest that interpretation of the intrapartum CTG continues to pose major problems for practising obstetricians.

Fetal heart rate accelerations in second-stage labour; two case reports

Two cases of umbilical cord compression are reported in which variable decelerations in the fetal heart rate in the first stage of labour progressed to marked periodic accelerations in the second stage. A respiratory acidosis was present at birth in both cases.

Deafness after topical neomycin

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