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Handley SC, Salazar EG, Kunz SN, Lorch SA, Edwards EM. Transfer Patterns Among Infants Born at 28 to 34 Weeks' Gestation. Pediatrics 2024; 153:e2023063118. [PMID: 38268423 PMCID: PMC10827647 DOI: 10.1542/peds.2023-063118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Although postnatal transfer patterns among high-risk (eg, extremely preterm or surgical) infants have been described, transfer patterns among lower-risk populations are unknown. The objective was to examine transfer frequency, indication, timing, and trajectory among very and moderate preterm infants. METHODS Observational study of the US Vermont Oxford Network all NICU admissions database from 2016 to 2021 of inborn infants 280/7 to 346/7 weeks. Infants' first transfer was assessed by gestational age, age at transfer, reason for transfer, and transfer trajectory. RESULTS Across 467 hospitals, 294 229 infants were eligible, of whom 12 552 (4.3%) had an initial disposition of transfer. The proportion of infants transferred decreased with increasing gestational age (9.6% [n = 1415] at 28 weeks vs 2.4% [n = 2646] at 34 weeks) as did the median age at time of transfer (47 days [interquartile range 30-73] at 28 weeks vs 8 days [interquartile range 3-16] at 34 weeks). The median post menstrual age at transfer was 34 or 35 weeks across all gestational ages. The most common reason for transfer was growth or discharge planning (45.0%) followed by medical and diagnostic services (30.2%), though this varied by gestation. In this cohort, 42.7% of transfers were to a higher-level unit, 10.2% to a same-level unit, and 46.7% to a lower-level unit, with indication reflecting access to specific services. CONCLUSIONS Over 4% of very and moderate preterm infants are transferred. In this population, the median age of transfer is later and does not reflect immediate care needs after birth, but rather the provision of risk-appropriate care.
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Affiliation(s)
- Sara C. Handley
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Elizabeth G. Salazar
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Sarah N. Kunz
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Scott A. Lorch
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Erika M. Edwards
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Larner College of Medicine, The University of Vermont, Burlington, Vermont
- Department of Mathematics and Statistics, The University of Vermont, Burlington, Vermont
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2
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Fang JL, Umoren RA, Whyte H, Limjoco J, Makkar A, Behl S, Lo MD, White L, Culjat M, Taylor JS, Kathuria S, Webb MO, Schad T, Shafranski S, Yankanah R, Herrin J, Demaerschalk BM. Evaluating the feasibility of a multicenter teleneonatology clinical effectiveness trial. Pediatr Res 2023; 94:1555-1561. [PMID: 37208433 DOI: 10.1038/s41390-023-02659-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/21/2023] [Accepted: 05/07/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Our research consortium is preparing for a prospective multicenter trial evaluating the impact of teleneonatology on the health outcomes of at-risk neonates born in community hospitals. We completed a 6-month pilot study to determine the feasibility of the trial protocol. METHODS Four neonatal intensive care units ("hubs") and four community hospitals ("spokes") participated in the pilot-forming four hub-spoke dyads. Two hub-spoke dyads implemented synchronous, audio-video telemedicine consultations with a neonatologist ("teleneonatology"). The primary outcome was a composite feasibility score that included one point for each of the following: site retention, on-time screening log completion, no eligibility errors, on-time data submission, and sponsor site-dyad meeting attendance (score range 0-5). RESULTS For the 20 hub-spoke dyad months, the mean (range) composite feasibility score was 4.6 (4, 5). All sites were retained during the pilot. Ninety percent (18/20) of screening logs were completed on time. The eligibility error rate was 0.2% (3/1809). On-time data submission rate was 88.4% (84/95 case report forms). Eighty-five percent (17/20) of sponsor site-dyad meetings were attended by both hub and spoke site staff. CONCLUSIONS A multicenter teleneonatology clinical effectiveness trial is feasible. Learnings from the pilot study may improve the likelihood of success of the main trial. IMPACT A prospective, multicenter clinical trial evaluating the impact of teleneonatology on the early health outcomes of at-risk neonates born in community hospitals is feasible. A multidimensional composite feasibility score, which includes processes and procedures fundamental to completing a clinical trial, is useful for quantitatively measuring pilot study success. A pilot study allows the investigative team to test trial methods and materials to identify what works well or requires modification. Learnings from a pilot study may improve the quality and efficiency of the main effectiveness trial.
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Affiliation(s)
- Jennifer L Fang
- Division of Neonatal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Rachel A Umoren
- Division of Neonatology, Department of Pediatrics, University of Washington & Seattle Children's Hospital, Seattle, WA, USA
| | - Hilary Whyte
- The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Abhishek Makkar
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Supriya Behl
- Children's Research Center, Mayo Clinic, Rochester, MN, USA
| | - Mark D Lo
- Division of Emergency Medicine, Department of Pediatrics, University of Washington & Seattle Children's Hospital, Seattle, WA, USA
| | - Lauren White
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Marko Culjat
- The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Sangeet Kathuria
- William Osler Health Centre-Brampton Civic Hospital, Brampton, ON, Canada
| | | | - Todd Schad
- Sauk Prairie Healthcare, Prairie du Sac, WI, USA
| | | | | | - Jeph Herrin
- Division of Cardiology, Yale School of Medicine, New Haven, CT, USA
| | - Bart M Demaerschalk
- Department of Neurology and Center for Digital Health, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, USA
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3
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Jones P, Marchand-Martin L, Desplanches T, Diguisto C, Fresson J, Goffinet F, Dauger S, Ancel PY, Morgan AS. Survival and neurodevelopmental impairment of outborn preterm infants at 5.5 years of age: an EPIPAGE-2 prospective, matched study using multiple imputation. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2022-001619. [PMID: 36645784 PMCID: PMC9756224 DOI: 10.1136/bmjpo-2022-001619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/29/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To determine whether birth outside a level-3 centre (outborn) is associated with a difference in the combined outcome of mortality or moderate-to-severe neurological impairment at 5.5 years of age compared with birth in a level-3 centre (inborn) when antenatal steroids and gestational age (GA) are accounted for. DESIGN Individual matched study nested within a prospective cohort. Each outborn infant was matched using GA and antenatal steroids with a maximum of four inborns. Conditional logistic regression was used to calculate ORs before being adjusted using maternal and birth characteristics. Analyses were carried out after multiple imputation for missing data. SETTING EPIPAGE-2 French national prospective cohort including births up to 34 weeks GA inclusive. PATIENTS Outborn and inborn control infants selected between 24 and 31 weeks GA were followed in the neonatal period and to 2 and 5.5 years. 3335 infants were eligible of whom all 498 outborns and 1235 inborn infants were included-equivalent to 2.5 inborns for each outborn. MAIN OUTCOME MEASURE Survival without moderate-to-severe neurodevelopmental impairment at 5.5 years. RESULTS Chorioamnionitis, pre-eclampsia, caesarian birth and small-for-dates were more frequent among inborns, and spontaneous labour and antepartum haemorrhage among outborns. There was no difference in the main outcome measure at 5.5 years of age (adjusted OR 1.09, 95% CI 0.82 to 1.44); sensitivity analyses suggested improved outcomes at lower GAs for inborns. CONCLUSION In this GA and steroid matched cohort, there was no difference in survival without moderate-to-severe neurodevelopmental impairment to 5.5 years of age between inborn and outborn very preterm children. This suggests steroids might be important in determining outcomes.
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Affiliation(s)
- Peter Jones
- SAMU de Paris, Necker-Enfants Malades Hospitals, Paris, France.,Paediatric Intensive Care, Hôpital Robert Debré, Robert-Debré Mother-Child University Hospital Mobile Service of Urgences and Reanimation, Paris, France
| | - Laetitia Marchand-Martin
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre of Research in Epidemiology and StatisticS (CRESS), Université Paris Cité, INSERM, INRAE, Paris, France
| | - Thomas Desplanches
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre of Research in Epidemiology and StatisticS (CRESS), Université Paris Cité, INSERM, INRAE, Paris, France.,Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland.,Pôle de Gynécologie-Obstétrique, Médecine Fœtale et Stérilité Conjugale, Dijon University Hospital, Dijon, France
| | - Caroline Diguisto
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre of Research in Epidemiology and StatisticS (CRESS), Université Paris Cité, INSERM, INRAE, Paris, France.,Maternité Olympe de Gouges, CHRU Tours Pôle de Gynécologie Obstétrique Médecine fœtale et Reproduction, Tours, France
| | - Jeanne Fresson
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre of Research in Epidemiology and StatisticS (CRESS), Université Paris Cité, INSERM, INRAE, Paris, France.,Population Health Office, DREES, Paris, France.,Department of Medical Information, University Hospital (CHRU) Nancy, Nancy, France
| | - François Goffinet
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre of Research in Epidemiology and StatisticS (CRESS), Université Paris Cité, INSERM, INRAE, Paris, France.,Department of Obstetrics and Gynaecology, Maternité Port-Royal, Association Publique - Hôpitaux de Paris, Paris, France
| | - Stéphane Dauger
- Paediatric Intensive Care Unit, Robert-Debré Mother-Child University Hospital, Paris, France
| | - Pierre-Yves Ancel
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre of Research in Epidemiology and StatisticS (CRESS), Université Paris Cité, INSERM, INRAE, Paris, France.,Clinical Investigation Center P1419, APHP, Paris, France
| | - Andrei Scott Morgan
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre of Research in Epidemiology and StatisticS (CRESS), Université Paris Cité, INSERM, INRAE, Paris, France .,EGA Institute for Women's Health, UCL, London, UK.,Pôle Femmes-Parents-Enfants, Service de réanimation et médecine néonatale, Hôpital Nord, Assistance Publique - Hôpitaux de Marseille, Marseille, France
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4
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Usuda H, Carter S, Takahashi T, Newnham JP, Fee EL, Jobe AH, Kemp MW. Perinatal care for the extremely preterm infant. Semin Fetal Neonatal Med 2022; 27:101334. [PMID: 35577715 DOI: 10.1016/j.siny.2022.101334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Being born preterm (prior to 37 weeks of completed gestation) is a leading cause of childhood death up to five years of age, and is responsible for the demise of around one million preterm infants each year. Rates of prematurity, which range from approximately 5 to 18% of births, are increasing in most countries. Babies born extremely preterm (less than 28 weeks' gestation) and in particular, in the periviable (200/7-256/7 weeks) period, are at the highest risk of death, or the development of long-term disabilities. The perinatal care of extremely preterm infants and their mothers raises a number of clinical, technical, and ethical challenges. Focusing on 'micropremmies', or those born in the periviable period, this paper provides an update regarding the aetiology and impacts of periviable preterm birth, advances in the antenatal, intrapartum, and acute post-natal management of these infants, and a review of counselling/support approaches for engaging with the infant's family. It concludes with an overview of emerging technology that may assist in improving outcomes for this at-risk population.
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Affiliation(s)
- Haruo Usuda
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Sean Carter
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore
| | - Tsukasa Takahashi
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - John P Newnham
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Erin L Fee
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Alan H Jobe
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Perinatal Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Centre, University of Cincinnati, Cincinnati, OH, 45229, USA
| | - Matthew W Kemp
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore; School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, 6150, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan.
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5
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Abstract
Neonatal tele-resuscitation programs use synchronous audio-video telemedicine systems to connect neonatologists with community hospital care teams during high risk resuscitations. Using tele-resuscitation, remote neonatologists can visualize and actively guide the resuscitation and stabilization of at-risk neonates. The feasibility of tele-resuscitation has been proven, and early evidence suggests that tele-resuscitation improves the quality of care, reduces unnecessary medical transports, and may generate a net savings to the health system. Community hospital staff and remote neonatologists are highly satisfied with tele-resuscitation programs. Tele-resuscitation presents an opportunity to improve healthcare delivery for neonates regardless of their birth location. The neonatology community should work to identify and rigorously study the value tele-resuscitation can bring to neonates, their families, and care teams.
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Affiliation(s)
- Jennifer L Fang
- Division of Neonatal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States.
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6
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Chang YS, Liang FW, Lin YJ, Lu TH, Lin CH. Neonatal and infant mortality of very-low-birth-weight infants in Taiwan: Does the level of delivery hospital matter? Pediatr Neonatol 2021; 62:419-427. [PMID: 34020899 DOI: 10.1016/j.pedneo.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 01/31/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND To study the distribution of the birthplaces of very-low-birth-weight (VLBW) infants and examine whether delivery at different levels of hospital affects neonatal and infant mortality. METHODS This population-based cohort study was retrieved from Taiwan Maternal and Child Health Database. Livebirth singleton VLBW infants born between 2011 and 2014, with BW between 500 and 1499 g and gestational age ≥22 weeks were enrolled. The main outcomes were risk-adjusted odds ratios (aOR) of neonatal and infant mortality by birthplace, which was categorized as medical center (MC), regional hospital (RH), district hospital (DH), and clinic (C) based on Taiwan's hospital accreditation system. RESULTS Of 4560 VLBW infants enrolled, 3005 (66%) were born in MCs, 1181 (26%) in RHs, 213 (5%) in DHs, and 161 (4%) in Cs. Neonatal mortality rates were 10%, 15%, 16%, 17%, and infant mortality rates were 13%, 17%, 18%, 21%, if born in MCs, RHs, DHs and Cs, respectively. The aORs for neonatal and infant mortality were 1.94 (95% CI 1.53-2.48) and 1.67 (1.34-2.08) for those born in RHs, 2.26 (1.38-3.70) and 1.82 (1.16-2.86) for infants born in DHs/Cs, as compared to those born in MCs. For VLBW infants born in RHs, DHs, and Cs and postnatally transferred to MCs, the aORs of neonatal and infant mortality were lower than those who were not transferred. CONCLUSION VLBW infants born outside of MCs had higher neonatal and infant mortality and a two-fold higher risk of mortality than those born in MCs. When possible, VLBW infants should be born in MCs.
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Affiliation(s)
- Yu-Shan Chang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Fu-Wen Liang
- Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan; Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yuh-Jyh Lin
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tsung-Hsueh Lu
- NCKU Research Center for Health Data and Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chyi-Her Lin
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Pediatrics, E-Da Hospital, Kaohsiung, Taiwan; Department of Pediatrics, College of Medicine, I-Shou University, Kaohsiung, Taiwan.
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7
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The amniotic fluid cell-free transcriptome in spontaneous preterm labor. Sci Rep 2021; 11:13481. [PMID: 34188072 PMCID: PMC8242007 DOI: 10.1038/s41598-021-92439-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/03/2021] [Indexed: 02/03/2023] Open
Abstract
The amniotic fluid (AF) cell-free RNA was shown to reflect physiological and pathological processes in pregnancy, but its value in the prediction of spontaneous preterm delivery is unknown. Herein we profiled cell-free RNA in AF samples collected from women who underwent transabdominal amniocentesis after an episode of spontaneous preterm labor and subsequently delivered within 24 h (n = 10) or later (n = 28) in gestation. Expression of known placental single-cell RNA-Seq signatures was quantified in AF cell-free RNA and compared between the groups. Random forest models were applied to predict time-to-delivery after amniocentesis. There were 2385 genes differentially expressed in AF samples of women who delivered within 24 h of amniocentesis compared to gestational age-matched samples from women who delivered after 24 h of amniocentesis. Genes with cell-free RNA changes were associated with immune and inflammatory processes related to the onset of labor, and the expression of placental single-cell RNA-Seq signatures of immune cells was increased with imminent delivery. AF transcriptomic prediction models captured these effects and predicted delivery within 24 h of amniocentesis (AUROC = 0.81). These results may inform the development of biomarkers for spontaneous preterm birth.
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8
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Pan S, Jiang S, Lin S, Lee SK, Cao Y, Lin Z. Outcome of very preterm infants delivered outside tertiary perinatal centers in China: a multi-center cohort study. Transl Pediatr 2021; 10:306-314. [PMID: 33708516 PMCID: PMC7944173 DOI: 10.21037/tp-20-232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND To describe the incidence of outborns among very preterm infants (VPIs, <32 weeks of gestation) in Chinese perinatal centers and to examine the association of outborn status with adverse outcomes. METHODS A cohort study enrolling all VPIs admitted to 18 perinatal centers in China from May 1st, 2015 to April 30th, 2018. Neonatal outcomes including rates of discharge against medical advice (DAMA), in-hospital mortality, overall mortality, severe intraventricular hemorrhage (IVH) or periventricular leukomalacia (PVL), sepsis, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC) and severe retinopathy of prematurity (ROP) were compared between outborn and inborn infants. A multivariate logistic regression model was used to estimate the independent association of outborn status with neonatal outcomes. RESULTS Among 12,014 VPIs, 1,991 (16.6%) infants were outborn. Outborn infants had lower Apgar scores and higher illness severity score on admission. Mothers of outborn infants were less likely to receive antenatal steroids, prenatal care and caesarean section. The incidence of DAMA (18.0% vs. 12.5%, P<0.001), overall mortality (19.9% vs. 15.8%, P<0.001) and severe brain injury (10.8% vs. 9.1%, P=0.024) of outborn infants were significantly higher than inborn infants. Outborn status was independently associated with increased risks of DAMA (aOR, 1.6; 95% CI: 1.4-1.8), overall-hospital mortality (aOR, 1.3; 95% CI: 1.1-1.5) and severe IVH/PVL (aOR, 1.2; 95% CI: 1.0-1.5). CONCLUSIONS The incidence of outborn VPIs was high in China. Outborn infants were more likely to be delivered in an uncontrolled situation and were at significantly higher risk of neonatal mortality and severe brain injury compared with inborn infants. Quality improvement efforts are needed to facilitate in-utero transfer of high-risk pregnancies to tertiary centers.
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Affiliation(s)
- Shulin Pan
- Department of Neonatology, The Second Affiliated Hospital & Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Siyuan Jiang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Su Lin
- Department of Neonatology, The Second Affiliated Hospital & Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Shoo K Lee
- Maternal-Infant Care Research Centre and Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Obstetrics and Gynecology and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Zhenlang Lin
- Department of Neonatology, The Second Affiliated Hospital & Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
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9
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Watson H, McLaren J, Carlisle N, Ratnavel N, Watts T, Zaima A, Tribe RM, Shennan AH. All the right moves: why in utero transfer is both important for the baby and difficult to achieve and new strategies for change. F1000Res 2020; 9. [PMID: 32913633 PMCID: PMC7429922 DOI: 10.12688/f1000research.25923.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 01/20/2023] Open
Abstract
The best way to ensure that preterm infants benefit from relevant neonatal expertise as soon as they are born is to transfer the mother and baby to an appropriately specialised neonatal facility before birth (“
in utero”). This review explores the evidence surrounding the importance of being born in the right unit, the advantages of
in utero transfers compared to
ex utero transfers, and how to accurately assess which women are at most risk of delivering early and the challenges of
in utero transfers. Accurate identification of the women most at risk of preterm birth is key to prioritising who to transfer antenatally, but the administrative burden and pathway variation of
in utero transfer in the UK are likely to compromise optimal clinical care. Women reported the impact that
in utero transfers have on them, including the emotional and financial burdens of being transferred and the anxiety surrounding domestic and logistical concerns related to being away from home. The final section of the review explores new approaches to reforming the
in utero transfer process, including learning from outside the UK and changing policy and guidelines. Examples of collaborative regional guidance include the recent Pan-London guidance on
in utero transfers. Reforming the transfer process can also be aided through technology, such as utilising the CotFinder app. In utero transfer is an unavoidable aspect of maternity and neonatal care, and the burden will increase if preterm birth rates continue to rise in association with increased rates of multiple pregnancy, advancing maternal age, assisted reproductive technologies, and obstetric interventions. As funding and capacity pressures on health services increase because of the COVID-19 pandemic, better prioritisation and sustained multi-disciplinary commitment are essential to maximise better outcomes for babies born too soon.
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Affiliation(s)
- Helena Watson
- Guy's and St Thomas NHS Foundation Trust, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - James McLaren
- Gosford Hospital, Gosford, New South Wales, Australia
| | - Naomi Carlisle
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | | | - Tim Watts
- Guy's and St Thomas NHS Foundation Trust, London, UK
| | | | - Rachel M Tribe
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Andrew H Shennan
- Guy's and St Thomas NHS Foundation Trust, London, UK.,Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
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10
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Ladhani NNN. Management of Impending Periviable Delivery. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020. [DOI: 10.1007/s13669-020-00299-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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11
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Gogcu S, Aboudi D, Kase J, LaGamma E, Brumberg HL. Presence of neonatal intensive care services at birth hospital and early intervention enrollment in infants ≤1500 g. J Perinat Med 2020; 48:/j/jpme.ahead-of-print/jpm-2019-0393/jpm-2019-0393.xml. [PMID: 32284452 DOI: 10.1515/jpm-2019-0393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/09/2020] [Indexed: 11/15/2022]
Abstract
Objectives To determine whether the receipt of therapeutic services of very-low-birth-weight (VLBW; ≤1500 g) neonates inadvertently delivered at community Level 2 and 3 neonatal intensive care units (NICUs) compared with those born at a well-baby nursery (WBN; Level 1) differed. Methods This is a retrospective study of neonates who were born at Level 1 (WBN), 2, 3, and 4 NICUs and discharged from a Level 4 hospital (n = 529). All infants were evaluated at the Regional Neonatal Follow-up Program at 12 ± 1 months corrected gestational age (CA) and assessed for use of therapeutic services including: early intervention (EI), occupational therapy (OT), physical therapy (PT), speech therapy (ST), and special education (SE). Results Compared to infants born at community Level 2 and 3 NICU hospitals, those outborn at a community Level 1 WBN had significantly higher utilization of EI (90% vs. 62%) and PT (83% vs. 61%) at 12 months CA. This association persisted when controlling for covariates. Infants who required EI had significantly lower Bayley-III cognitive scores at 3 years of age. Conclusion VLBW infants outborn at WBN (Level 1) hospitals required more outpatient therapeutic services than those born at hospitals with NICU facilities. These results suggest that delivering at the appropriate community hospital level of care might be advantageous for long-term outcomes.
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Affiliation(s)
- Semsa Gogcu
- Wake Forest University, Brenner Children's Hospital, Winston-Salem, NC, USA
| | - David Aboudi
- New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Jordan Kase
- Maria Fareri Children's Hospital at Westchester Medical Center, Division of Newborn Medicine, Department of Pediatrics, Valhalla, NY, USA
| | - Edmund LaGamma
- Maria Fareri Children's Hosp-NY Med College, Peds - Newborn Med, Valhalla, NY, USA
| | - Heather Lynn Brumberg
- Maria Fareri Children's Hospital at Westchester Medical Center, Division of Newborn Medicine, Department of Pediatrics, Valhalla, NY, USA
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12
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Ismail AQT, Boyle EM, Pillay T. The impact of level of neonatal care provision on outcomes for preterm babies born between 27 and 31 weeks of gestation, or with a birth weight between 1000 and 1500 g: a review of the literature. BMJ Paediatr Open 2020; 4:e000583. [PMID: 32232179 PMCID: PMC7101044 DOI: 10.1136/bmjpo-2019-000583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE There is evidence that birth and care in a maternity service associated with a neonatal intensive care unit (NICU) is associated with improved survival in preterm babies born at <27 weeks of gestation. We conducted a systematic review to address whether similar gains manifested in babies born between 27+0 and 31+6 weeks (hereafter 27 and 31 weeks) of gestation, or in those with a birth weight between 1000 and 1500 g. METHODS We searched Embase, Medline and CINAHL databases for studies comparing outcomes for babies born between 27 and 31 weeks or between 1000 and 1500 g birth weight, based on designation of the neonatal unit where the baby was born or subsequently cared for (NICU vs non-NICU setting). A modified QUIPS (QUality In Prognostic Studies) tool was used to assess quality. RESULTS Nine studies compared outcomes for babies born between 27 and 31 weeks of gestation and 11 studies compared outcomes for babies born between 1000 and 1500 g birth weight. Heterogeneity in comparator groups, birth locations, gestational age ranges, timescale for mortality reporting, and description of morbidities facilitated a narrative review as opposed to a meta-analysis. CONCLUSION Due to paucity of evidence, significant heterogeneity and potential for bias, we were not able to answer our question-does place of birth or care affect outcomes for babies born between 27 and 31 weeks? This supports the need for large-scale research to investigate place of birth and care for babies born in this gestational age range.
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Affiliation(s)
- Abdul Qader Tahir Ismail
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK.,Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Elaine M Boyle
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Thillagavathie Pillay
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK.,School of Medicine and Clinical Practice, Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
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13
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Fang JL, Mara KC, Weaver AL, Clark RH, Carey WA. Outcomes of outborn extremely preterm neonates admitted to a NICU with respiratory distress. Arch Dis Child Fetal Neonatal Ed 2020; 105:33-40. [PMID: 31079068 DOI: 10.1136/archdischild-2018-316244] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 04/04/2019] [Accepted: 04/07/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the risk of mortality and morbidity between outborn and propensity score-matched inborn extremely preterm neonates. SETTING Multiple neonatal intensive care units (NICU) across the USA. PATIENTS Singleton neonates born at 22-29 weeks' gestation with no major anomalies who were admitted to a NICU and discharged between 2000 and 2014. Outborn neonates were restricted to those who transferred into a NICU on the day of birth. METHODS The association between inborn-outborn status and the time-to-event outcomes of in-hospital mortality and necrotising enterocolitis (NEC) were assessed using Cox proportional hazards regression. Logistic regression was used to assess the remaining secondary outcomes: retinopathy of prematurity requiring treatment (tROP), chronic lung disease (CLD), periventricular leucomalacia (PVL) and severe intraventricular haemorrhage (IVH). Since outborn status was not random, we used 1:1 propensity score matching to reduce the imbalance in illness severity. RESULTS There were 59 942 neonates (7991 outborn) included in the study. Outborn neonates had poorer survival than inborns and higher rates of NEC, severe IVH, tROP and PVL. Inborn-outborn disparities in mortality were reduced over the study period. When analysing the matched cohort (6524 matched pairs), outborns were less likely to die in-hospital compared with inborns (HR 0.84, 95% CI 0.77 to 0.91). However, outborns experienced higher rates of NEC (HR 1.14, 95% CI 1.04 to 1.25), severe IVH (OR 1.52, 95% CI 1.38 to 1.68), tROP (OR 1.45, 95% CI 1.25 to 1.69) and CLD (OR 1.12, 95% CI 1.01 to 1.24). CONCLUSION Additional research is needed to understand the contributors to increased morbidity for outborn extremely preterm neonates and identify interventions that mitigate this risk.
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Affiliation(s)
- Jennifer L Fang
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Reese H Clark
- CREQS, Pediatrix Medical Group, Sunrise, Florida, USA
| | - William A Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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14
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Howes A, Hilditch C, Keir A. What clinical practice strategies have been shown to decrease incidence rates of intraventricular haemorrhage in preterm infants? J Paediatr Child Health 2019; 55:1269-1278. [PMID: 31629388 DOI: 10.1111/jpc.14613] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 08/13/2019] [Accepted: 08/16/2019] [Indexed: 12/14/2022]
Abstract
AIM To answer the clinical question 'In infants about to be delivered and admitted to neonatal units, what clinical practice strategies, compared to standard care, have been shown to decrease incidence rates of intraventricular haemorrhage (IVH)?' METHODS MEDLINE via Ovid (1943 to 5 January 2018), Embase via Ovid (1974 to 5 January 2018) and the Cochrane Library (5 January 2018) were searched for relevant articles. RESULTS A total of 478 articles, after the removal of duplicates, were found and screened by title and abstract. Forty full-text articles were subsequently reviewed, and 19 were included as relevant to the structured clinical question. An additional article was included based on expert advice. CONCLUSION There are various levels of research evidence for clinical practice strategies to decrease the incidence rates of IVH. Higher-quality evidence suggests that antenatal corticosteroids decrease the rates of IVH, and multiple evidence-based intervention bundles implemented in the neonatal unit are associated with decreased rates of IVH.
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Affiliation(s)
- Alexander Howes
- Department of Neonatal Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Cathie Hilditch
- Department of Neonatal Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia.,SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Discipline of Obstetrics and Gynaecology, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Amy Keir
- Department of Neonatal Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia.,SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Discipline of Obstetrics and Gynaecology, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.,Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
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15
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Ladhani NNN, Chari RS, Dunn MS, Jones G, Shah P, Barrett JFR. No. 347-Obstetric Management at Borderline Viability. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 39:781-791. [PMID: 28859764 DOI: 10.1016/j.jogc.2017.03.108] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The primary objective of this guideline was to develop consensus statements to guide clinical practice and recommendations for obstetric management of a pregnancy at borderline viability, currently defined as prior to 25+6 weeks. INTENDED USERS Clinicians involved in the obstetric management of women whose fetus is at the borderline of viability. TARGET POPULATION Women presenting for possible birth at borderline viability. EVIDENCE This document presents a summary of the literature and a general consensus on the management of pregnancies at borderline viability, including maternal transfer and consultation, administration of antenatal corticosteroids and magnesium sulfate, fetal heart rate monitoring, and considerations in mode of delivery. Medline, EMBASE, and Cochrane databases were searched using the following keywords: extreme prematurity, borderline viability, preterm, pregnancy, antenatal corticosteroids, mode of delivery. The results were then studied, and relevant articles were reviewed. The references of the reviewed studies were also searched, as were documents citing pertinent studies. The evidence was then presented at a consensus meeting, and statements were developed. VALIDATION METHODS The content and recommendations were developed by the consensus group from the fields of Maternal-Fetal Medicine, Neonatology, Perinatal Nursing, Patient Advocacy, and Ethics. The quality of evidence was rated using criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework (reference 1). The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. METHODS The quality of evidence was rated using the criteria described in the Grading of Recommendations, Assessment, Development, and Evaluation methodology framework. The interpretation of strong and weak recommendations is described later. The Summary of Findings is available upon request. BENEFITS, HARMS, AND COSTS A multidisciplinary approach should be used in counselling women and families at borderline viability. The impact of obstetric interventions in the improvement of neonatal outcomes is suggested in the literature, and if active resuscitation is intended, then active obstetric interventions should be considered. GUIDELINE UPDATE Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations. SPONSORS This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada and the Women and Babies Program at Sunnybrook Health Sciences Centre. RECOMMENDATIONS
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16
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Aboudi D, Shah SI, La Gamma EF, Brumberg HL. Impact of neonatologist availability on preterm survival without morbidities. J Perinatol 2018; 38:1009-1016. [PMID: 29743659 DOI: 10.1038/s41372-018-0103-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/09/2018] [Accepted: 02/21/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We assessed birth hospital level and neonatal outcomes within a model of regionalization featuring neonatologists at all levels of care, including well-baby nurseries without an accompanying neonatal intensive care unit. METHODS Data were analyzed by NY State adaptation of American Academy of Pediatrics defined levels of care; n = 998, 23-30 weeks gestational age, 400-1250 g birth weight, and admitted to the regional center (2006-2015). Primary outcomes were survival, neurologic survival, and intact survival. RESULTS Level III hospitals transferred 82% of neonates ≥24 h of life compared to ≤2% at Level I or II hospitals (p < 0.05). Primary outcomes were equivalent for Levels I vs. II born neonates with similar postnatal age at transfer and similar to inborn rates (Levels I and II vs. IV). CONCLUSIONS When transferred within 24 h, Levels I or II born infants had equivalent outcomes to inborn Level IV infants in a model of neonatologist availability at all deliveries.
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Affiliation(s)
- David Aboudi
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA
| | - Shetal I Shah
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA
| | - Edmund F La Gamma
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA
| | - Heather L Brumberg
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA.
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17
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F LaGamma E, Brumberg HL, Aboudi D, Shah S. Making a business case for a model of regionalization with neonatologist availability at all facilities: one institution's financial tell-all. J Perinatol 2018; 38:959-962. [PMID: 29977012 DOI: 10.1038/s41372-018-0157-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/29/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Edmund F LaGamma
- Division of Newborn Medicine, New York Medical College, The Regional Neonatal Intensive Care Unit, Maria Fareri Children's Hospital at Westchester Medical Center, 100 Woods Road, Valhalla, NY, 10595, USA
| | - Heather L Brumberg
- Division of Newborn Medicine, New York Medical College, The Regional Neonatal Intensive Care Unit, Maria Fareri Children's Hospital at Westchester Medical Center, 100 Woods Road, Valhalla, NY, 10595, USA
| | - David Aboudi
- Division of Newborn Medicine, New York Medical College, The Regional Neonatal Intensive Care Unit, Maria Fareri Children's Hospital at Westchester Medical Center, 100 Woods Road, Valhalla, NY, 10595, USA
| | - Shetal Shah
- Division of Newborn Medicine, New York Medical College, The Regional Neonatal Intensive Care Unit, Maria Fareri Children's Hospital at Westchester Medical Center, 100 Woods Road, Valhalla, NY, 10595, USA.
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18
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Amer R, Moddemann D, Seshia M, Alvaro R, Synnes A, Lee KS, Lee SK, Shah PS, Synnes A, Ting J, Cieslak Z, Sherlock R, Yee W, Aziz K, Toye J, Fajardo C, Kalapesi Z, Sankaran K, Daspal S, Mukerji A, Da O, Nwaesei C, Dunn M, Lemyre B, Dow K, Pelausa E, Barrington K, Drolet C, Piedboeuf B, Claveau M, Faucher D, Bertelle V, Masse E, Canning R, Makary H, Ojah C, Monterrosa L, Deshpandey A, Afifi J, Kajetanowicz A, Pillay T, Sauvé R, Hendson L, Reichert A, Bodani J, Sankaran K, deCabo C, Nwaesei C, Daboval T, Dow K, Lee D, Ly L, Kelly E, el Helou S, Church P, Pelausa E, Beltempo M, Levebrve F, Demers C, Bélanger S, Canning R, Monterrosa L, Makary H, Vincer M, Murphy P. Neurodevelopmental Outcomes of Infants Born at <29 Weeks of Gestation Admitted to Canadian Neonatal Intensive Care Units Based on Location of Birth. J Pediatr 2018; 196:31-37.e1. [PMID: 29305231 DOI: 10.1016/j.jpeds.2017.11.038] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/01/2017] [Accepted: 11/15/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare mortality and neurodevelopmental outcomes of outborn and inborn preterm infants born at <29 weeks of gestation admitted to Canadian neonatal intensive care units (NICUs). STUDY DESIGN Data were obtained from the Canadian Neonatal Network and Canadian Neonatal Follow-up Network databases for infants born at <29 weeks of gestation admitted to NICUs from April 2009 to September 2011. Rates of death, severe neurodevelopmental impairment (NDI), and overall NDI were compared between outborn and inborn infants at 18-21 months of age, corrected for prematurity. RESULTS Of 2951 eligible infants, 473 (16%) were outborn. Mean birth weight (940 ± 278 g vs 897 + 237 g), rates of treatment with antenatal steroids (53.9% vs 92.9%), birth weight small for gestational age (5.3% vs 9.4%), and maternal college education (43.7% vs 53.9%) differed between outborn and inborn infants, respectively (all P values <.01). The median Score for Neonatal Acute Physiology-II (P = .01) and Apgar score at 5 minutes (P < .01) were higher in inborn infants. Severe brain injury was more common among outborn infants (25.3% vs 14.7%, P < .01). Outborn infants had higher odds of death or severe NDI (aOR 1.7, 95% CI 1.3-2.2), death or overall NDI (aOR 1.6, 95% CI 1.2-2.2), death (aOR 2.1, 95% CI 1.5-3.0), and cerebral palsy (aOR 1.9, 95% CI 1.1-3.3). CONCLUSIONS The composite outcomes of death or neurodevelopmental impairment were significantly higher in outborn compared with inborn infants admitted to Canadian NICUs. Adverse outcomes were mainly attributed to increased mortality and cerebral palsy in outborn neonates.
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Affiliation(s)
- Reem Amer
- Department of Pediatrics, University of Manitoba, Canada
| | | | - Mary Seshia
- Department of Pediatrics, University of Manitoba, Canada
| | - Ruben Alvaro
- Department of Pediatrics, University of Manitoba, Canada
| | - Anne Synnes
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kyong-Soon Lee
- Department of Pediatrics, Sickkids Hospital, Toronto, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Shoo K Lee
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Prakesh S Shah
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada.
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19
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[Analysis of obstetric-pediatric care in the perinatal period. Are births before 31 weeks' gestation in level 2B maternity units avoidable?]. Arch Pediatr 2017; 24:1188-1196. [PMID: 29153908 DOI: 10.1016/j.arcped.2017.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 07/02/2017] [Accepted: 09/12/2017] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Regionalization of perinatal care has been developed to improve the survival of preterm babies. The mortality rate is higher among very premature infants born outside level-3 maternity units. The objective of this study was to evaluate the preventability of these very premature births occurring outside recommendations within level-2B maternity units. The secondary objective was to describe the care of premature infants between 23 and 24 weeks. METHODS This is a single-center retrospective qualitative study of the care delivery pathways. Thirty-one deliveries in which the fetus was alive between 23 and 30 weeks+6 days occurred in a level-2B maternity unit in Thionville, France, between 1 January 2013 and 31 December 2015. After oral presentation of the cases, a level 2-3 multidisciplinary committee of experts in Lorraine evaluated the preventability criteria and reasons, and divided the deliveries into three groups: (i) birth in level-2B institutions avoidable, (ii) inevitable with factors related to the mother or the organization of care, (iii) with no inevitable factors. RESULTS Out of the 31 deliveries included, the committee classified six deliveries as preventable, 14 as inevitable with factors, and 11 as inevitable with no factors. The criteria for preventability of birth in a level-2B unit were underestimation of maternal and fetal risk, an erroneous initial estimate of term or preterm labor, and two births in the upper limits of the French recommendations for in utero transfer. Nineteen of the 35 premature infants before 31 weeks' gestation died, 16 children were transferred to a level-3 maternity ward, and 16 children were allowed to go home. CONCLUSION Analysis of the obstetrical-pediatric care course by an expert committee determined the preventability of the average birth and prematurity in level-2B maternity units in Lorraine for a small but significant number of cases. The local regionalization of neonatal care could be improved by the application of this method of analysis to other maternity wards in the Lorraine network.
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Ladhani NNN, Chari RS, Dunn MS, Jones G, Shah P, Barrett JF. No 347-Prise en charge obstétricale près de la limite de viabilité du fœtus. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:792-804. [DOI: 10.1016/j.jogc.2017.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Lemyre B, Moore G. Les conseils et la prise en charge en prévision d’une naissance extrêmement prématurée. Paediatr Child Health 2017. [DOI: 10.1093/pch/pxx059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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22
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Lemyre B, Moore G. Counselling and management for anticipated extremely preterm birth. Paediatr Child Health 2017; 22:334-341. [PMID: 29485138 DOI: 10.1093/pch/pxx058] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Counselling couples facing the birth of an extremely preterm infant is a complex and delicate task, entailing both challenges and opportunities. This revised position statement proposes using a prognosis-based approach that takes the best estimate of gestational age into account, along with additional factors, including estimated fetal weight, receipt of antenatal corticosteroids, singleton versus multiple pregnancy, fetal status and anomalies on ultrasound and place of birth. This statement updates data on survival in Canada, long-term neurodevelopmental disability at school age and quality of life, with focus on strategies to communicate effectively with parents. It also proposes a framework for determining the prognosis-based management option(s) to present to parents when initiating the decision-making process. This statement replaces the 2012 position statement.
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Affiliation(s)
- Brigitte Lemyre
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Gregory Moore
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
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23
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Thompson K, Gardiner J, Resnick S. Outcome of outborn infants at the borderline of viability in Western Australia: A retrospective cohort study. J Paediatr Child Health 2016; 52:728-33. [PMID: 27149045 DOI: 10.1111/jpc.13187] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2016] [Indexed: 01/08/2023]
Abstract
AIM Preterm infants have a high risk of morbidity and mortality, which increases with decreasing gestational age. Inborn infants (infants born in tertiary perinatal centres) have higher survival and lower morbidity than outborn infants. We aimed to compare short-term and 1-year developmental outcomes of outborn infants at the borderline of viability (≥23 to ≤25 + 6 weeks gestation) with a similar cohort of inborn infants in the sole tertiary perinatal centre in Western Australia from 2001 to 2011. METHODS This was a retrospective cohort study. Outborn infants ≥23 to ≤25 + 6 weeks gestation who survived to be transported to the Neonatal Intensive Care Unit (NICU) in the perinatal centre were contemporaneously matched to the next inborn infant of comparable gestation and birth weight. We compared mortality, morbidity (including intraventricular haemorrhage, necrotising enterocolitis and chronic lung disease) and Griffiths General Quotient scores at 1-year corrected age. RESULTS There were 54 outborn and 519 inborn births in the gestational age range during the study period. Thirty-five (65%) outborn infants were transported to the NICU. Of the outborn infants, 21/54 (39%) survived to discharge compared with 375/519 (72%) inborn infants. For the 35 outborn infants transported to NICU, 14 (40%) died, compared with 6/35 (17%) of inborn infants. There were no differences in short-term and developmental outcomes in surviving infants. CONCLUSIONS Outborn extremely preterm infants <26 weeks gestation have higher mortality than inborn counterparts. However, those transported to a tertiary NICU have similar morbidity and developmental outcomes.
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Affiliation(s)
- Kirsten Thompson
- Neonatology Clinical Care Unit, King Edward Memorial Hospital, Subiaco, Western Australia, Australia.,Centre for Neonatal Research and Education, University of Western Australia, Perth, Western Australia, Australia.,Newborn Emergency Transport Service, Princess Margaret Hospital, Subiaco, Western Australia, Australia
| | - Jacqueline Gardiner
- Neonatology Clinical Care Unit, King Edward Memorial Hospital, Subiaco, Western Australia, Australia
| | - Steven Resnick
- Neonatology Clinical Care Unit, King Edward Memorial Hospital, Subiaco, Western Australia, Australia.,Centre for Neonatal Research and Education, University of Western Australia, Perth, Western Australia, Australia.,Newborn Emergency Transport Service, Princess Margaret Hospital, Subiaco, Western Australia, Australia
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Terrin G, Conte F, Scipione A, Aleandri V, Di Chiara M, Bacchio E, Messina F, De Curtis M. New architectural design of delivery room reduces morbidity in preterm neonates: a prospective cohort study. BMC Pregnancy Childbirth 2016; 16:63. [PMID: 27008185 PMCID: PMC4804574 DOI: 10.1186/s12884-016-0849-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 03/16/2016] [Indexed: 11/10/2022] Open
Abstract
Background A multidisciplinary committee composed of a panel of experts, including a member of the American Academy of Pediatrics and American Institute of Architects, has suggested that the delivery room (DR) and the neonatal intensive care units (NICU) room should be directly interconnected. We aimed to investigate the impact of the architectural design of the DR and the NICU on neonatal outcome. Methods Two cohorts of preterm neonates born at < 32 weeks of gestational age, consecutively observed during 2 years, were compared prospectively before (Cohort 1: “conventional DR”) and after architectural renovation of the DR realized in accordance with specific standards (Cohort 2: “new concept of DR”). In Cohort 1, neonates were initially cared for a conventional resuscitation area, situated in the DR, and then transferred to the NICU, located on a separate floor of the same hospital. In Cohort 2 neonates were assisted at birth directly in the NICU room, which was directly connected to the DR via a pass-through door. The primary outcome of the study was morbidity, defined by the proportion of neonates with at least one complication of prematurity (i.e., late-onset sepsis, patent ductus arteriosus, intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, retinopathy of prematurity and necrotizing enterocolitis). Secondary outcomes were mortality and duration of hospitalization. Statistical analysis was performed using standard methods by SPSS software. Results We enrolled 106 neonates (56 in Cohort 1 and 50 in Cohort 2). The main clinical and demographic characteristics of the 2cohorts were similar. Moderate hypothermia (body temperature ≤ 35.9 ° C) was more frequent in Cohort 1 (57 %) compared with Cohort 2 (24 %, p = 0.001). Morbidity was increased in Cohort 1 (73 %) compared with Cohort 2 (44 %, p = 0.002). No statistically significant differences in mortality and median duration of hospitalization were observed between the 2 cohorts of the study. Conclusions If realized according to the proposed architectural standards, renovation of DR and NICU may represent an opportunity to reduce morbidity in preterm neonates.
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Affiliation(s)
- Gianluca Terrin
- Department of Gynecology-Obstetrics and Perinatal Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Francesca Conte
- Department of Pediatrics, "Sapienza" University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Antonella Scipione
- Department of Gynecology-Obstetrics and Perinatal Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Vincenzo Aleandri
- Department of Gynecology-Obstetrics and Perinatal Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.,Research Center on Evaluation of Quality in Medicine - CEQUAM, "Sapienza" University of Rome, Rome, Italy
| | - Maria Di Chiara
- Department of Gynecology-Obstetrics and Perinatal Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Erica Bacchio
- Department of Gynecology-Obstetrics and Perinatal Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Messina
- Department of Perinatal Medicine, Evangelical Hospital "V. Betania", Via Argine 604, Naples, 80147, Italy
| | - Mario De Curtis
- Department of Pediatrics, "Sapienza" University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
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Hossain S, Shah PS, Ye XY, Darlow BA, Lee SK, Lui K. Outborns or Inborns: Where Are the Differences? A Comparison Study of Very Preterm Neonatal Intensive Care Unit Infants Cared for in Australia and New Zealand and in Canada. Neonatology 2016; 109:76-84. [PMID: 26583768 DOI: 10.1159/000441272] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 09/24/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Very preterm infants born outside tertiary centers are at higher risks of adverse outcomes than inborn infants. Regionalization of perinatal care has been introduced worldwide to improve outcomes. OBJECTIVE To compare the risk-adjusted outcomes of both inborn and outborn infants cared for in tertiary neonatal intensive care units in Australia and New Zealand and in Canada. METHODS Deidentified data of infants <32 weeks' gestational age from the 29 Australian and New Zealand Neonatal Network units (ANZNN; n = 9,893) and 26 Canadian Neonatal Network units (CNN; n = 7,133) between 2005 and 2007 were analyzed for predischarge adverse outcomes. RESULTS ANZNN had lower rates of outborns compared to CNN (13 vs. 19%), particularly of late admissions (>2 days of age; 5.8 vs. 22.2% of outborns) who had high morbidity rates. After adjusting for confounding variables including gestation, ANZNN inborn infants had lower odds of chronic lung disease [CLD; 17.0 vs. 23.3%; adjusted odds ratio (AOR) = 0.70, 95% CI: 0.64-0.77], severe neurological injuries on ultrasound (SNI; 4.1 vs. 6.7%; AOR = 0.62, 95% CI: 0.53-0.73), severe retinopathy (5.6 vs. 7%; AOR = 0.71, 95% CI: 0.59-0.84) and necrotizing enterocolitis (3.5 vs. 5.4%; AOR = 0.67, 95% CI: 0.56-0.79), but no difference in mortality odds. After excluding the late outborn admissions, ANZNN outborns had lower odds of SNI (AOR = 0.43, 95% CI: 0.32-0.58) and CLD (AOR = 0.63, 95% CI: 0.49-0.81) than CNN. CONCLUSIONS ANZNN inborn and early admitted outborn infants had lower odds of neonatal morbidities than their CNN counterparts. However, compared to ANZNN, the higher CNN rates of outborns and their late admissions are likely related to the differences in regionalization and referral practices, and may explain differences in outcomes.
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Affiliation(s)
- Sadia Hossain
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, N.S.W., Australia
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Yodoshi T, Tipton E, Rouse CA. A Case of Delayed Interval Delivery with a Successful Hospital Move. Case Rep Pediatr 2015; 2015:802097. [PMID: 26413366 PMCID: PMC4568053 DOI: 10.1155/2015/802097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 08/23/2015] [Indexed: 11/17/2022] Open
Abstract
This report is the first case of delayed interval twin delivery in which the first infant and mother survived without major morbidity following transport to another facility. In addition, this case is only the second report of asynchronous delivery in which both twins survived and neither suffered any major morbidity. A 30-year-old G5P1031 African American female with a diamniotic/dichorionic twin pregnancy presented to U.S. Naval Hospital Okinawa, Japan, at 22 + 5 weeks due to vaginal bleeding. At 23 + 2 weeks, Twin A was born secondary to advanced cervical dilation. Twin A's birth weight was 650 g with APGAR scores of 6 (1 min) and 7 (5 min). Following delivery of Twin A, Placenta A was left in utero with high ligation of the umbilical cord. Due to a scheduled hospital move, the mother and Twin A were transported to the new facility at Camp Foster. Three weeks later, Twin B was delivered at 26 + 4 weeks. Twin B's birth weight was 930 g with APGAR scores of 3 (1 min) and 7 (5 min). Both twins were discharged without IVH, PVL, ROP, or CLD. This case demonstrates the possibility of transporting both the mother and surviving infant A to a higher level of care prior to delivery of subsequent fetuses.
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Affiliation(s)
- Toshifumi Yodoshi
- Department of Pediatrics, United States Naval Hospital Okinawa, Camp Foster, Futenma, Ginowan, Okinawa, Japan
| | - Elizabeth Tipton
- Department of Obstetrics and Gynecology, United States Naval Hospital Okinawa, Camp Foster, Futenma, Ginowan, Okinawa, Japan
| | - Christopher A. Rouse
- Department of Neonatology, United States Naval Hospital Okinawa, Camp Foster, Futenma, Ginowan, Okinawa, Japan
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Farr A, Kiss H, Holzer I, Husslein P, Hagmann M, Petricevic L. Effect of asymptomatic vaginal colonization with Candida albicans on pregnancy outcome. Acta Obstet Gynecol Scand 2015; 94:989-96. [PMID: 26084843 DOI: 10.1111/aogs.12697] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 06/10/2015] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Vaginal infection is a major causative factor of preterm delivery. The present study was performed to evaluate the effect of asymptomatic vaginal colonization with Candida albicans at early gestation on pregnancy outcome. MATERIAL AND METHODS From 2005 to 2014, a total of 8447 women with singleton pregnancies between 10(+0) and 16(+0) gestational weeks were routinely subjected to an antenatal infection screen-and-treat program. Vaginal smears were Gram-stained and microscopically evaluated, and data were retrospectively analyzed. Women exposed to Candida received clotrimazole and were re-tested after 4-6 weeks. Treatment was repeated in case of recurrence. Women with normal or intermediate vaginal flora were considered as non-exposed. Bacterial vaginosis and trichomoniasis were assessed and treated as well. Descriptive data analysis, chi-squared testing and multiple regression analysis with adjustment for potential confounders were performed. Rates of asymptomatic vaginal infections, preterm delivery and low birthweight served as the main outcomes measures. RESULTS A normal or intermediate flora was found in 6708 (79.4%) of the screened women; 1142 women (13.5%) showed asymptomatic C. albicans infection. Of this group, 185 women (2.2%) had a recurrence of Candida on vaginal smears. Compared with the non-exposed women with normal or intermediate flora, those with recurrent candidiasis had higher rates of preterm delivery (11.9% vs. 9.5%) and of low birthweight (10.8% vs. 8.0%), as confirmed in the multiple model (p = 0.02). CONCLUSIONS Recurrent asymptomatic vaginal colonization with Candida in early pregnancy is associated with preterm delivery and low birthweight. Routine screening and consequent treatment for candidiasis could improve pregnancy outcomes.
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Affiliation(s)
- Alex Farr
- Division of Obstetrics and Fetomaternal Medicine, Department of Obstetrics and Gynecology, Medical University Vienna, Vienna, Austria
| | - Herbert Kiss
- Division of Obstetrics and Fetomaternal Medicine, Department of Obstetrics and Gynecology, Medical University Vienna, Vienna, Austria
| | - Iris Holzer
- Division of Obstetrics and Fetomaternal Medicine, Department of Obstetrics and Gynecology, Medical University Vienna, Vienna, Austria
| | - Peter Husslein
- Division of Obstetrics and Fetomaternal Medicine, Department of Obstetrics and Gynecology, Medical University Vienna, Vienna, Austria
| | - Michael Hagmann
- Section for Medical Statistics (IMS), Center of Medical Statistics, Informatics and Intelligent Systems, Medical University Vienna, Vienna, Austria
| | - Ljubomir Petricevic
- Division of Obstetrics and Fetomaternal Medicine, Department of Obstetrics and Gynecology, Medical University Vienna, Vienna, Austria
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Lecoeur C, Thibon P, Prime L, Mercier PY, Balouet P, Durin L, Deon G, Lefevre P, Coutour XL, Guillois B, Dreyfus M. Frequency, causes and avoidability of outborn births in a French regional perinatal network. Eur J Obstet Gynecol Reprod Biol 2014; 179:22-6. [DOI: 10.1016/j.ejogrb.2014.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 04/21/2014] [Accepted: 05/09/2014] [Indexed: 11/16/2022]
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Jefferies AL, Kirpalani HM. Counselling and management for anticipated extremely preterm birth. Paediatr Child Health 2013; 17:443-6. [PMID: 24082807 DOI: 10.1093/pch/17.8.443] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Extremely preterm birth (birth between 22(0/7) and 25(6/7) weeks' gestational age [GA]) often requires parents to make complex choices about the care of their infant. Health professionals have a significant role in providing information, guidance and support. Parents facing the birth of an extremely preterm infant should have the chance to meet with both obstetrical and paediatric/neonatal care providers to receive accurate information about their infant's prognosis, provided with clarity and compassion. Decision making between parents and health professionals should be an informed and shared process, with documentation of all management decisions. Consultation with and transfer to tertiary perinatal centres are important for the care of both mother and fetus. As the survival of infants born before or at 22 completed weeks' GA remains uncommon, a noninterventional approach is recommended, whereas at 23, 24 and 25 weeks' GA, counselling about outcomes and decision making should be individualized for each infant and family, using factors which influence prognosis. All extremely preterm infants who are not resuscitated, or for whom resuscitation is not successful, must receive compassionate palliative care.
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Jefferies AL, Kirpalani HM. Les conseils et la prise en charge en prévision d’une très grande prématurité. Paediatr Child Health 2012. [DOI: 10.1093/pch/17.8.445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Clerc J, Doret M, Decullier E, Claris O, Picaud JC, Dupuis O. [Is it possible to prevent preterm births outside of level-3 maternity wards? Experience of Greater Lyon perinatal network]. ACTA ACUST UNITED AC 2011; 39:412-7. [PMID: 21742533 DOI: 10.1016/j.gyobfe.2011.02.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Accepted: 02/28/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The main objective of this study was to calculate the percentage of preterm births before 28 weeks gestational age (weeks GA) outside level-3 maternity wards and determine how many could have been prevented. METHODS This was an observational, multicenter, retrospective cohort study, which included all the deliveries that occurred between 24 and 27 weeks GA + 6 days in the Greater Lyon perinatal network (France) occurring between first of March 2008 and first of March 2009. In utero transfers (IUTs) and newborn transfers (NBTs) which were carried out outside the network, medical abortions, and foetal deaths in utero were excluded. The duration between patient's arrival in the level 1 and 2 maternity and birth was compared at the 97(th) percentile of the mother's transfer time in level-3 maternity. Births that occurred outside of level-3 maternity wards were considered avoidable each time the first duration was more than the second. RESULTS During the study period, 113 infants were born alive between 24 and 27 weeks GA+6 days in the network. They were all included in the study. Ninety were born in a level-3 maternity ward and 23 were born in level-1 and 2 maternity wards (20%). There were 35 requests for IUT and 28 were carried out (80%). In 65% of non-level 3 births, no IUT was requested. In 17% of cases, an IUT request could have prevented births in level 1/2 maternity wards. If twin pregnancies had been transferred to a level-3 maternity ward, 26% of non-level 3 births would have been avoided. If all high-risk pregnancies had been transferred to a level-3 maternity ward, 40% of non-level 3 births would have been avoided. DISCUSSION AND CONCLUSION Any time a pregnant woman is hospitalized in a type 1/2 maternity ward before 28 weeks GA, doctors should consider an in utero transfer to a level-3 maternity ward. It may be possible to lower the birth-rate of non-level 3 births by a targeted increase in in utero transfers and by transferring high-risk pregnancies to a level-3 maternity ward.
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Affiliation(s)
- J Clerc
- Service de gynécologie-obstétrique, centre hospitalier Lyon Sud, 165 chemin du Grand-Revoyet, Pierre-Bénite cedex, France.
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Chung MY, Fang PC, Chung CH, Chen CC, Hwang KP, Chen FS. Comparison of neonatal outcome for inborn and outborn very low-birthweight preterm infants. Pediatr Int 2009; 51:233-6. [PMID: 19405922 DOI: 10.1111/j.1442-200x.2008.02734.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of the present study was to compare the neonatal outcome of very low-birthweight (VLBW) preterm infants with regard to inborn and outborn status in a medical center of Southern Taiwan, where short-distance neonatal transport is the rule and maternal transport was not well established. METHODS This retrospective study included outborn VLBW preterm infants admitted to the neonatal intensive care unit of Chang Gung Memorial Hospital at Kaohsiung after neonatal transport during the period from 1999 through 2003. An equal number of inborn preterm infants matched for gender and birthweight were included as controls. Infants with lethal congenital anomalies or who died in the delivery room were excluded. Data were collected from reviewing medical charts. RESULTS A total of 34 inborn VLBW infants and 34 outborn VLBW infants with neonatal transport were included. Chronic lung disease (CLD) was significantly more frequent in the outborn group according to McNemar test (P = 0.0124) and logistic regression. Logistic regression also showed that outborn status (P = 0.0173) and birthweight (P = 0.0024) were the two most important risk factors for development of CLD. CONCLUSION Well-trained short distance neonatal transport is useful and valuable for VLBW infants with gestation age of 27-34 weeks in Southern Taiwan. The respiratory outcome, however, was poor in the outborn group in terms of incidence of CLD. To improve the respiratory outcome, further modification of respiratory care during transportation or antenatal maternal transport is crucial.
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Affiliation(s)
- Mei-Yung Chung
- Department of Pediatrics, Section of Neonatology, Chang Gung Memorial Hospital, Niao Sung Hsiang, Kaohsiung, Taiwan.
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Vento M, Aguar M, Leone TA, Finer NN, Gimeno A, Rich W, Saenz P, Escrig R, Brugada M. Using intensive care technology in the delivery room: a new concept for the resuscitation of extremely preterm neonates. Pediatrics 2008; 122:1113-6. [PMID: 18977992 DOI: 10.1542/peds.2008-1422] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Máximo Vento
- Neonatal Research Unit and Research Foundation, Hospital Universitario Materno Infantil La Fe, Valencia,
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Zeitlin J, Gwanfogbe CD, Delmas D, Pilkington H, Jarreau PH, Chabernaud JL, Bréart G, Papiernik E. Risk factors for not delivering in a level III unit before 32 weeks of gestation: results from a population-based study in Paris and surrounding districts in 2003. Paediatr Perinat Epidemiol 2008; 22:126-35. [PMID: 18298686 DOI: 10.1111/j.1365-3016.2007.00921.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Delivery of very preterm babies in maternity units with on-site neonatal intensive care (level III units) is associated with lower mortality and morbidity. This analysis explores risk factors for not delivering in a level III unit, using data from a population-based study of very preterm births in Paris and surrounding districts in 2003. The sample for analysis included resident women with a fetus alive at the onset of labour between 24 and 31 weeks of gestation (n = 641). Characteristics of women delivering in and those not in level III units were compared using logistic regression. Further analysis was carried out for the subgroup of women not already scheduled to deliver in a level III unit. Twenty-nine per cent of women did not deliver in level III units; in the subgroup scheduled to deliver in level I or II units, 43% were not transferred. Women were less likely to deliver in a level III unit if they had a singleton pregnancy, a gestation of <26 weeks or at 31 weeks, experienced antenatal haemorrhaging, lived in socially deprived neighbourhoods or at a greater distance from the nearest level III. Women scheduled to deliver in a maternity unit with a special care nursery were also less likely to deliver in a level III unit. In contrast, preterm rupture of membranes and fetal growth restriction increased the likelihood of a level III delivery. These results underline the importance of controlling for clinical characteristics when analysing perinatal outcome by place of delivery and show how socioeconomic factors, known to impact on the risk of having a preterm birth, can also affect access to appropriate care.
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Affiliation(s)
- Jennifer Zeitlin
- INSERM, UMR S149, Epidemiological Research Unit on Perinatal and Women's Health, and Université Pierre et Marie Curie-Paris 6, Paris, France.
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Van Reempts P, Gortner L, Milligan D, Cuttini M, Petrou S, Agostino R, Field D, den Ouden L, Børch K, Mazela J, Carrapato M, Zeitlin J. Characteristics of neonatal units that care for very preterm infants in Europe: results from the MOSAIC study. Pediatrics 2007; 120:e815-25. [PMID: 17908739 DOI: 10.1542/peds.2006-3122] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We sought to compare guidelines for level III units in 10 European regions and analyze the characteristics of neonatal units that care for very preterm infants. METHODS The MOSAIC (Models of Organising Access to Intensive Care for Very Preterm Births) project combined a prospective cohort study on all births between 22 and 31 completed weeks of gestation in 10 European regions and a survey of neonatal unit characteristics. Units that admitted > or = 5 infants at < 32 weeks of gestation were included in the analysis (N = 111). Place of hospitalization of infants who were admitted to neonatal care was analyzed by using the cohort data (N = 4947). National or regional guidelines for level III units were reviewed. RESULTS Six of 9 guidelines for level III units included minimum size criteria, based on number of intensive care beds (6 guidelines), neonatal admissions (2), ventilated patients (1), obstetric intensive care beds (1), and deliveries (2). The characteristics of level III units varied, and many were small or unspecialized by recommended criteria: 36% had fewer than 50 very preterm annual admissions, 22% ventilated fewer than 50 infants annually, and 28% had fewer than 6 intensive care beds. Level II units were less specialized, but some provided mechanical ventilation (57%) or high-frequency ventilation (20%) or had neonatal surgery facilities (17%). Sixty-nine percent of level III and 36% of level I or II units had continuous medical coverage by a qualified pediatrician. Twenty-two percent of infants who were < 28 weeks of gestation were treated in units that admitted fewer than 50 very preterm infants annually (range: 2%-54% across the study regions). CONCLUSIONS No consensus exists in Europe about size or other criteria for NICUs. A better understanding of the characteristics associated with high-quality neonatal care is needed, given the high proportion of very preterm infants who are cared for in units that are considered small or less specialized by many recommendations.
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Affiliation(s)
- Patrick Van Reempts
- Department of Neonatology, Antwerp University Hospital, University of Antwerp and Study Centre for Perinatal Epidemiology, Flanders, Belgium.
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Bartels DB, Wenzlaff P, Poets CF. Obstetrical volume and early neonatal mortality in preterm infants. Eur J Epidemiol 2007; 22:791-8. [PMID: 17902029 DOI: 10.1007/s10654-007-9182-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2007] [Accepted: 09/10/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Regionalised perinatal care with antenatal transfer of high risk pregnancies to Level III centres is beneficial. However, levels of care are usually not linked to caseload requirements, which remain a point for discussion. We aimed to investigate the impact of annual delivery volume on early neonatal mortality among very preterm births. METHODS All neonates with gestational age 24-30 weeks, born 1991-1999 in Lower Saxony were included into this population-based cohort study (n = 5,083). Large units were defined as caring for more than 1,000 deliveries/year, large NICUs as those with at least 36 annual very low birthweight (<1,500 g, VLBW) admissions. Main outcome criterion was mortality until day 7. Adjusted Odds Ratios (adj. OR) and 95% confidence intervals (CI) were calculated based on generalised estimating equation models, accounting for correlation of individuals within units. RESULTS Within the first week of life, 20.6% of all neonates deceased; 10.2% were stillbirths, 3.7% died in the delivery unit, and 6.7% in the NICU. The crude OR for early neonatal mortality after having been delivered in a small delivery unit (excluding stillbirths) was 1.36 (95%CI 1.04-1.78; adj. OR 1.16 (0.82-1.63)). It increased to 1.96 (1.54-2.48; adj. OR 1.21 (0.86-1.70)) after the inclusion of stillbirths. CONCLUSION This study has shown a slight, but non-significant association between obstetrical volume and early neonatal mortality. In future studies the impact of caseload on outcome may become more evident when referring to high-risk patients instead of to the overall number of deliveries.
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Affiliation(s)
- Dorothee B Bartels
- Department of Epidemiology, Public Medicine and Healthcare Systems Research, Hannover Medical School, Carl-Neuberg-Str. 1, OE 5410, 30625 Hannover, Germany.
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Marret S, Ancel PY, Marpeau L, Marchand L, Pierrat V, Larroque B, Foix-L'Hélias L, Thiriez G, Fresson J, Alberge C, Rozé JC, Matis J, Bréart G, Kaminski M. Neonatal and 5-Year Outcomes After Birth at 30–34 Weeks of Gestation. Obstet Gynecol 2007; 110:72-80. [PMID: 17601899 DOI: 10.1097/01.aog.0000267498.95402.bd] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the rates of in-hospital death, neonatal complications, and 5-year outcomes of infants born at 30-34 weeks of gestation. METHODS In nine regions of France, all 2,020 stillbirths and live births at 30, 31, and 32 weeks in 1997 and all 457 births at 33 and 34 weeks in April and October 1997 were recorded. Survivors were evaluated at 5 years of age. RESULTS Increasing gestational age from 30 to 34 weeks was associated with progressive decreases in in-hospital mortality (from 8.1% to 0.4%) and neonatal complications (respiratory distress syndrome, 43.8% to 2.6%; maternofetal infections, 7.2% to 2.6%; and severe white matter injury, 5.5% to 1.3%). Although infants at 33 and 34 weeks of gestation rarely experienced necrotizing enterocolitis, bronchopulmonary dysplasia, or nosocomial infections, they still required endotracheal ventilation, antibiotics, or parenteral nutrition. At 5 years of age, older gestational age was associated with significant decreases in rates of cerebral palsy (6.3% at 30 weeks and 0.7% at 34 weeks) and mild to severe cognitive impairments (35.3% at 30 weeks and 23.9% at 34 weeks). In singletons, preterm rupture of membranes or preterm labor carried an increased risk of cerebral palsy but not of cognitive impairment. CONCLUSION Neonates born at 30-34 weeks experienced substantial morbidity and often required admission to neonatal intensive care units. These outcomes suggest that prolonging pregnancies beyond 34 weeks may be desirable whenever possible. Infants born at 30-34 weeks should be carefully monitored to ensure prompt detection and management of neurodevelopmental impairment.
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Affiliation(s)
- Stéphane Marret
- Department of Neonatal Medicine, Rouen University Hospital and Inserm Avenir Research Group, Institute for Biomedical Research, University of Rouen, Rouen, France.
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Arad I, Braunstein R, Ergaz Z, Peleg O. Bruising at birth: antenatal associations and neonatal outcome of extremely low birth weight infants. Neonatology 2007; 92:258-63. [PMID: 17556844 DOI: 10.1159/000103744] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Accepted: 02/19/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND Early studies have identified severe cranial bruising as a risk factor for intraventricular hemorrhage (IVH) in premature infants but the nature of this association has not been evaluated. OBJECTIVE To identify antenatal predictors and associations with neonatal outcome of bruised extremely low birth weight infants. METHODS A cohort study comparing 34 bruised and 116 non-bruised infants (birth weight <or=1,000 g), delivered in two 'Hadassah' university hospitals in Jerusalem between 2000 and 2004. Bruised patients were divided according to the severity of bruising. A univariate model was first applied to examine the associations of the individual independent variables with the outcome variable, followed with a logistic stepwise regression model, performed for each of the outcome variables. RESULTS In a stepwise logistic regression on 'Any bruising' and 'Severe bruising', only increasing gestational age and exposure to antenatal steroids prior to delivery maintained a protective association with bruising (OR = 0.74; 95% CI: 0.58-0.94; p = 0.015, OR = 0.38; 95% CI: 0.16-0.90; p = 0.028, respectively, for 'Any bruising', and OR = 0.77; 95% CI: 0.59-1.01; p = 0.055, OR = 0.29; 95% CI: 0.12-0.73; p = 0.008, respectively, for 'Severe bruising'). In a stepwise logistic regression analysis, with 'Any bruising' and 'Severe bruising' as forced-in variables and controlling for gestational age, small for gestational age, Apgar scores, respiratory distress syndrome and pneumothorax, 'Severe bruising', but not 'Any bruising', was found to be associated significantly with severe IVH (OR = 5.60; 95% CI: 1.86-16.82; p = 0.002), whereas both 'Any bruising' and 'Severe bruising' were significantly associated with mortality (OR = 6.31; 95% CI: 2.37-16.83; p = 0.000, OR = 3.33; 95% CI: 1.16-9.52; p = 0.025 respectively). CONCLUSION Antenatal exposure to steroids and increasing gestational age are associated with a lower incidence of bruising at birth in extremely low birth weight infants. Severe bruising at birth is associated with increased incidence of severe intraventricular hemorrhage and mortality.
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Affiliation(s)
- Ilan Arad
- Department of Neonatology and Center for Safety and Quality, Hebrew University - Hadassah Medical Center, Jerusalem, Israel.
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Wilson AK, Martel MJ, Arsenault MY, Cargill YM, Delaney M, Daniels S, Gleason T, Iglesias S, Klein MC, MacKinnon CJ, Roggensack A. Maternal transport policy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2006; 27:956-63. [PMID: 16411011 DOI: 10.1016/s1701-2163(16)30742-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Jones HP, Karuri S, Cronin CMG, Ohlsson A, Peliowski A, Synnes A, Lee SK. Actuarial survival of a large Canadian cohort of preterm infants. BMC Pediatr 2005; 5:40. [PMID: 16280080 PMCID: PMC1315360 DOI: 10.1186/1471-2431-5-40] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2005] [Accepted: 11/09/2005] [Indexed: 11/25/2022] Open
Abstract
Background The increased survival of preterm and very low birth weight infants in recent years has been well documented but continued surveillance is required in order to monitor the effects of new therapeutic interventions. Gestation and birth weight specific survival rates most accurately reflect the outcome of perinatal care. Our aims were to determine survival to discharge for a large Canadian cohort of preterm infants admitted to the neonatal intensive care unit (NICU), and to examine the effect of gender on survival and the effect of increasing postnatal age on predicted survival. Methods Outcomes for all 19,507 infants admitted to 17 NICUs throughout Canada between January 1996 and October 1997 were collected prospectively. Babies with congenital anomalies were excluded from the study population. Gestation and birth weight specific survival for all infants with birth weight <1,500 g (n = 3419) or gestation ≤30 weeks (n = 3119) were recorded. Actuarial survival curves were constructed to show changes in expected survival with increasing postnatal age. Results Survival to discharge at 24 weeks gestation was 54%, compared to 82% at 26 weeks and 95% at 30 weeks. In infants with birth weights 600–699, survival to discharge was 62%, compared to 79% at 700–799 g and 96% at 1,000–1,099 g. In infants born at 24 weeks gestational age, survival was higher in females but there were no significant gender differences above 24 weeks gestation. Actuarial analysis showed that risk of death was highest in the first 5 days. For infants born at 24 weeks gestation, estimated survival probability to 48 hours, 7 days and 4 weeks were 88 (CI 84,92)%, 70 (CI 64, 76)% and 60 (CI 53,66)% respectively. For smaller birth weights, female survival probabilities were higher than males for the first 40 days of life. Conclusion Actuarial analysis provides useful information when counseling parents and highlights the importance of frequently revising the prediction for long term survival particularly after the first few days of life.
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Affiliation(s)
- Huw P Jones
- Department of Pediatrics, St Mary's Hospital, Portsmouth, UK
- Canadian Neonatal Network Coordinating Centre, Edmonton, AB, Canada
| | - Stella Karuri
- Canadian Neonatal Network Coordinating Centre, Edmonton, AB, Canada
| | | | - Arne Ohlsson
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Abraham Peliowski
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Anne Synnes
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Shoo K Lee
- Canadian Neonatal Network Coordinating Centre, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Archivée: Politique quant au transport de la mére. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2005. [DOI: 10.1016/s1701-2163(16)30743-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Shah PS, Shah V, Qiu Z, Ohlsson A, Lee SK. Improved outcomes of outborn preterm infants if admitted to perinatal centers versus freestanding pediatric hospitals. J Pediatr 2005; 146:626-31. [PMID: 15870665 DOI: 10.1016/j.jpeds.2005.01.030] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To examine whether admission hospital type (13 perinatal centers vs 4 freestanding pediatric hospitals) was associated with differences in risk and illness severity adjusted mortality and morbidity among outborn preterm infants. STUDY DESIGN Records of singleton outborn infants < or =32 weeks' gestational age (n = 605) admitted to 17 tertiary level neonatal intensive care units participating in the Canadian Neonatal Network for the period 1996 to 1997 were examined. RESULTS Outborn infants admitted to freestanding pediatric hospitals were at higher risk of death (adjusted odds ratio [AOR], 2.25; 95% confidence interval [CI], 1.20, 4.20), nosocomial infection (AOR, 2.48; 95% CI, 1.64, 3.73), and oxygen dependency at 28 days of age (AOR, 1.77; 95% CI, 1.14, 2.75) when compared with outborn infants admitted to perinatal centers. CONCLUSIONS After adjustment for perinatal risks and admission illness severity, outborn infants had better outcomes if they were admitted to perinatal centers compared with freestanding pediatric hospitals.
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Affiliation(s)
- Prakesh S Shah
- Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Palmer KG, Kronsberg SS, Barton BA, Hobbs CA, Hall RW, Anand KJS. Effect of inborn versus outborn delivery on clinical outcomes in ventilated preterm neonates: secondary results from the NEOPAIN trial. J Perinatol 2005; 25:270-5. [PMID: 15616613 DOI: 10.1038/sj.jp.7211239] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the effect of birth center (inborn versus outborn) on morbidity and mortality for preterm neonates (23 to 32 weeks) using data collected prospectively within a uniform protocol. STUDY DESIGN Secondary analyses of data from the NEurologic Outcomes and Pre-emptive Analgesia In Neonates (NEOPAIN) trial (n=898) were performed to evaluate the effect of inborn versus outborn delivery on neonatal outcomes, including the occurrence of severe intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), chronic lung disease (CLD), and mortality. RESULTS Outborn babies were more likely to have severe IVH (p=0.0005); this increased risk persisted after controlling for severity of illness. When adjustments for antenatal steroids were added, the effect of birth center was no longer significant. Neither the occurrences of PVL or CLD nor mortality were significantly different between the inborn and outborn infants. CONCLUSION Outborn babies are more likely to have severe IVH than inborn babies, perhaps because their mothers are less likely to receive antenatal steroids. Improvements in antenatal steroid administration to high-risk women may substantially reduce neonatal morbidity.
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Affiliation(s)
- Kristine G Palmer
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
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Abstract
The need for resuscitation of a distressed newborn in delivery room is more and more easily predictable. The two principal reasons are improvement of obstetrical survey and best perinatal regionalisation. Perinatal asphyxia and premature labour, especially before 32 weeks of gestational age, are the more frequent situation needing resuscitation at birth. A good survey of pregnancy and labor, verification of availability and efficiency of care devices and material in the delivery room are essential. In all guidelines respiratory resuscitation is today the priority in the first minutes. Non invasive positive pressure ventilation and early use of exogenous surfactant are the recent advances for the care of very premature baby in delivery room. Having a neonatal ventilator and pulse oximetry monitoring is recommended and can improve results. For the pregnant woman and the baby, maternal transfer if no contra-indications exist and when it is possible, is preferred to postnatal transportation in case of very premature labor or high risk pregnancy. In all the other situations neonatal transport must be strictly organised and realised by well-trained pediatric team, with adapted material and in the best conditions for security and comfort. The goal is to prevent any rupture until arrival in the referring neonatal intensive car unit.
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Affiliation(s)
- J-L Chabernaud
- SMUR pédiatrique des Hauts-de-Seine (SAMU 92) et service de pédiatrie et réanimation néonatales, hôpital Antoine-Béclère, 157 rue de la Porte-de-Trivaux, 92141 Clamart cedex, France.
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Hayter MA, Anderson L, Claydon J, Magee LA, Liston RM, Lee SK, von Dadelszen P. Variations in Early and Intermediate Neonatal Outcomes for Inborn Infants Admitted to a Canadian NICU and Born of Hypertensive Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2005; 27:25-32. [PMID: 15937579 DOI: 10.1016/s1701-2163(16)30168-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether neonatal intensive care unit (NICU) outcomes vary by centre for inborn neonates of hypertensive pregnancies and, if so, whether that variation might be related to between-centre variations in obstetric practice. METHODS The study comprised a prospective cohort of 13 505 singleton neonates admitted to 17 Canadian NICUs. Adjusting for potential confounders, we used multivariate regression to analyze the relation between centre of delivery and 6 dependent variables: (1) Apgar score < 7 at 5 minutes; (2) Score of Neonatal Acute Physiology-II (SNAP-II) score > or = 10; (3) neonatal death; (4) neonatal death or morbidity (owing to bronchopulmonary dysplasia [BPD], intraventricular hemorrhage [IVH], necrotizing enterocolitis [NEC], persistent ductus arteriosus [PDA], or periventricular leukomalacia [PVL]); (5) BPD alone; and (6) major neonatal morbidity (that is, at least one of IVH, PVL, NEC, or PDA). NICU practices known to influence these outcomes were included in the modelling for neonatal death and neonatal morbidity. In a sensitivity analysis for practice variation, antenatal steroid exposure was both included and excluded in each regression. RESULTS For 5 of the 6 dependent variables, we identified between-centre variation that was not explained solely by variation in antenatal corticosteroid use. Adjusted odds ratios varied from 0.11 to 5.6 (the reference centre was the median rate of the adverse outcome). CONCLUSIONS In the pregnancy hypertension setting, between-centre variations in practice are associated with variations in neonatal physiology and survival. For infants admitted to NICU, the obstetric management of hypertensive pregnancies appears to have an effect on both short- and medium-term neonatal outcomes, even after correction for NICU management.
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Affiliation(s)
- Megan A Hayter
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC
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Abstract
The concept of designations for hospital facilities that care for newborn infants according to the level of complexity of care provided was first proposed in 1976. Subsequent diversity in the definitions and application of levels of care has complicated facility-based evaluation of clinical outcomes, resource allocation and utilization, and service delivery. We review data supporting the need for uniform nationally applicable definitions and the clinical basis for a proposed classification based on complexity of care. Facilities that provide hospital care for newborn infants should be classified on the basis of functional capabilities, and these facilities should be organized within a regionalized system of perinatal care.
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Louis JM, Ehrenberg HM, Collin MF, Mercer BM. Perinatal intervention and neonatal outcomes near the limit of viability. Am J Obstet Gynecol 2004; 191:1398-402. [PMID: 15507972 DOI: 10.1016/j.ajog.2004.05.047] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate trends in the level of obstetric and neonatal intervention near the limit of viability and perinatal morbidity and mortality rates over time. STUDY DESIGN In this retrospective chart review, live-born infants who were delivered at 23 to 26 weeks of gestation and who weighed between 500 and 1500 g between 1990 and 2001 in an urban tertiary care center were identified. Maternal charts were reviewed for clinical characteristics and antenatal and intrapartum course. Neonatal charts were reviewed for short-term morbidities that included respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, and survival. The study group was divided into 2 cohorts (group I:1990-95; group II:1996-2001); the obstetrician's willingness to intervene, neonatal resuscitation efforts, infant mortality (in gestational age subgroups) rate, and short-term morbidity rate were compared. Multivariate analyses, which controlled for obstetrician willingness to intervene, neonatal resuscitation, cohort, and gestational age, were performed to evaluate infant survival in the entire cohort and for morbidity in the survivors. RESULTS Records for 260 mothers and 293 newborn infants were evaluated. Comparing the 2 cohorts (group I vs II), we found increases over time in intent to intervene for fetal indication (70% vs 89%; P = .0007), cesarean delivery for malpresentation (20% vs 42%; P = .0003), and survival (54% vs 70%; P = .003). Pregnancies in group 1 were less likely to have received antenatal steroids (7.7% vs 60%) or surfactant (39% vs 73%; P <.0001 for each). Survival increased with advancing delivery gestation (24%, 51%, 68%, and 85% at 23, 24, 25, and 26 weeks of gestation, respectively; P <.0001). However, among survivors, the incidences of necrotizing enterocolitis, retinopathy of prematurity, intraventricular hemorrhage, respiratory distress syndrome, sepsis, and bronchopulmonary dysplasia did not decline significantly with advancing gestational age, after controlling for other factors. CONCLUSION Obstetric intervention and aggressive neonatal resuscitation have increased for pregnancies delivered between 23 and 26 weeks of gestation over the past decade. Although survival has increased over time and with advancing gestational age at delivery, short-term morbidity in survivors is similar, regardless of gestational age in this cohort. A brief delay in delivery of those pregnancies who are at risk for delivery between 23 and 26 weeks of gestation may improve survival, although short-term morbidity in survivors will not be affected substantially.
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Affiliation(s)
- Judette M Louis
- Departments of Reproductive Biology and Obstetrics and Gynecology, Case Western University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
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