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Farooqi A, Hakansson S, Serenius F, Kallen K, Björklund L, Normann E, Domellöf M, Ådén U, Abrahamsson T, Elfvin A, Sävman K, Bergström PU, Stephansson O, Ley D, Hellstrom-Westas L, Norman M. One-year survival and outcomes of infants born at 22 and 23 weeks of gestation in Sweden 2004-2007, 2014-2016 and 2017-2019. Arch Dis Child Fetal Neonatal Ed 2023; 109:10-17. [PMID: 37290903 DOI: 10.1136/archdischild-2022-325164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/23/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To explore associations between perinatal activity and survival in infants born at 22 and 23 weeks of gestation in Sweden. DESIGN/SETTING Data on all births at 22 and 23 weeks' gestational age (GA) were prospectively collected in 2004-2007 (T1) or obtained from national registers in 2014-2016 (T2) and 2017-2019 (T3). Infants were assigned perinatal activity scores based on 3 key obstetric and 4 neonatal interventions. MAIN OUTCOME One-year survival and survival without major neonatal morbidities (MNM): intraventricular haemorrhage grade 3-4, cystic periventricular leucomalacia, surgical necrotising enterocolitis, retinopathy of prematurity stage 3-5 or severe bronchopulmonary dysplasia. The association of GA-specific perinatal activity score and 1-year survival was also determined. RESULTS 977 infants (567 live births and 410 stillbirths) were included: 323 born in T1, 347 in T2 and 307 in T3. Among live-born infants, survival at 22 weeks was 5/49 (10%) in T1 and rose significantly to 29/74 (39%) in T2 and 31/80 (39%) in T3. Survival was not significantly different between epochs at 23 weeks (53%, 61% and 67%). Among survivors, the proportions without MNM in T1, T2 and T3 were 20%, 17% and 19% for 22 weeks and 17%, 25% and 25% for 23 weeks' infants (p>0.05 for all comparisons). Each 5-point increment in GA-specific perinatal activity score increased the odds for survival in first 12 hours of life (adjusted OR (aOR) 1.4; 95% CI 1.3 to 1.6) in addition to 1-year survival (aOR 1.2; 95% CI 1.1 to 1.3), and among live-born infants it was associated with increased survival without MNM (aOR 1.3; 95% CI 1.1 to 1.4). CONCLUSION Increased perinatal activity was associated with reduced mortality and increased chances of survival without MNM in infants born at 22 and 23 weeks of GA.
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Affiliation(s)
- Aijaz Farooqi
- Department of Clinical Sciences, Pediatrics, Umeå University, Umea, Sweden
| | - Stellan Hakansson
- Department of Clinical Sciences, Pediatrics, Umeå University, Umea, Sweden
- Pediatrics, Swedish Neonatal Quality Register, Umeå Universitet, Umea, Sweden
| | - Fredrik Serenius
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Karin Kallen
- Department of Reproductive Epidemiology, Lund University, Lund, Sweden
| | - Lars Björklund
- Departments of Clinical Sciences and Pediatrics, Skåne University Hospital Lund, Lund, Sweden
| | - Erik Normann
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences-Pediatrics, Umeå universitet Medicinska fakulteten, Umea, Sweden
| | - Ulrika Ådén
- Woman and Child Health, Karolinska Institute, Stockholm, Sweden
| | - Thomas Abrahamsson
- Department of Biomedical and Clinical Sciences and Department of Pediatrics, Linköping University, Linkoping, Sweden
| | - Anders Elfvin
- Department of Pediatrics, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
- Department of Pediatrics, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Karin Sävman
- Department of Pediatrics, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Petra Um Bergström
- Clinical Science and Education at Sodersjukhuset, Karolinska Institute, Stockholm, Sweden
| | - Olof Stephansson
- Departments of Medicine and Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - David Ley
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden
| | | | - Mikael Norman
- Neonatal Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
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Anselem O, Goffinet F, Jarreau PH, Zeitlin J, Monier I. Perinatal survival among very preterm singletons born after detection of early-onset fetal growth restriction with or without maternal hypertensive disorders: A population-based study in France. Eur J Obstet Gynecol Reprod Biol 2023; 282:43-49. [PMID: 36634405 DOI: 10.1016/j.ejogrb.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To investigate the management and survival of very preterm singletons born because of fetal growth restriction (FGR) with or without maternal hypertensive disorders in France. STUDY DESIGN From a population-based cohort of very preterm births between 22 and 31 weeks in France in 2011, the study population included all non-anomalous singleton pregnancies delivered because of detected FGR with or without maternal hypertensive disorders. Antenatal detection of FGR was defined as an estimated fetal weight <10th percentile with or without fetal Doppler abnormalities or growth arrest. All fetuses were alive at the time of detection of FGR. Indicators of active perinatal management (antenatal steroids, pre-labor cesarean and birth in level 3 maternity unit) and fetal/neonatal outcomes (terminations of pregnancy (TOP), stillbirths, neonatal deaths and survival to discharge) were compared by gestational age between FGR associated with maternal hypertensive disorders and isolated FGR. RESULTS Overall, 398 pregnancies delivered before 32 weeks for FGR associated with hypertensive disorders and 234 for isolated FGR. Active perinatal care was rare before 26 weeks in both groups and about one in five cases associated with maternal hypertensive disorders received steroids and was born by prelabor cesarean compared to none for isolated FGR. Before 25 weeks of gestation age, more pregnancies resulted in TOP when FGR was associated with hypertensive disorders compared to isolated FGR (respectively, 76.2 % vs 28.0 % at 22-23 weeks, P = 0.002 and 57.9 % vs 21.1 % at 24 weeks, P = 0.028) whereas stillbirths were more common among isolated FGR (respectively, 23.8 % vs 72.0 % at 22-23 weeks, P = 0.002 and 36.8 % vs 73.7 % at 24 weeks, P = 0.030). Survival to discharge was higher at any gestational age when the cause of birth was FGR associated with hypertensive disorders compared to isolated FGR. CONCLUSION The management and pregnancy outcomes differed when FGR was associated with maternal hypertensive disorders or isolated. The proportion of TOP was higher when FGR was associated with hypertensive disorders and the proportion of stillbirths was higher in isolated FGR.
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Affiliation(s)
- Olivia Anselem
- Port-Royal Maternity Unit, Groupe Hospitalier Cochin Broca Hôtel-Dieu, AP-HP, Université Paris, FHU Prema, Paris, France
| | - François Goffinet
- Port-Royal Maternity Unit, Groupe Hospitalier Cochin Broca Hôtel-Dieu, AP-HP, Université Paris, FHU Prema, Paris, France; Université Paris Cité, Centre of Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM, INRA, Paris, France
| | - Pierre-Henri Jarreau
- Université Paris Cité, Centre of Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM, INRA, Paris, France; Department of Neonatal Medicine, Cochin-Port Royal Hospital, FHU PREMA, AP-HP Centre, Paris, France
| | - Jennifer Zeitlin
- Université Paris Cité, Centre of Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM, INRA, Paris, France
| | - Isabelle Monier
- Université Paris Cité, Centre of Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM, INRA, Paris, France.
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Boland RA, Cheong JLY, Doyle LW. Changes in long-term survival and neurodevelopmental disability in infants born extremely preterm in the post-surfactant era. Semin Perinatol 2021; 45:151479. [PMID: 34493405 DOI: 10.1016/j.semperi.2021.151479] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Extremely preterm birth before 28 weeks' gestation accounts for less than 1% of births in high-income countries but is associated with high rates of perinatal and infant mortality, and of neurodevelopmental disability in surviving children. Survival rates have increased over time, both overall, and within each week of gestational age since the introduction of exogenous surfactant into clinical care in the early 1990s. However, rates of major neurodevelopmental disability in survivors, whether they be in early childhood or at school-age, have not clearly improved in parallel with the increases in survival. An important strategy to improve survival free of major neurodevelopmental disability is to birth extremely preterm infants in a tertiary perinatal center, where specialist obstetric care for the mother and ongoing intensive care for the infant can both be provided without the potential morbidities associated with postnatal transfer.
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Affiliation(s)
- Rosemarie A Boland
- Clinical Sciences, Murdoch Children's Research, 50 Flemington Road, Parkville, VIC 3052, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia; Paediatric Infant Perinatal Emergency Retrieval, Royal Children's Hospital, Parkville, VIC, Australia.
| | - Jeanie L Y Cheong
- Clinical Sciences, Murdoch Children's Research, 50 Flemington Road, Parkville, VIC 3052, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia; Neonatal Services, Royal Women's Hospital, Parkville, VIC, Australia
| | - Lex W Doyle
- Clinical Sciences, Murdoch Children's Research, 50 Flemington Road, Parkville, VIC 3052, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia; Neonatal Services, Royal Women's Hospital, Parkville, VIC, Australia
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Nourkami-Tutdibi N, Tutdibi E, Faas T, Wagenpfeil G, Draper ES, Johnson S, Cuttini M, Rafei RE, Seppänen AV, Mazela J, Maier RF, Nuytten A, Barros H, Rodrigues C, Zeitlin J, Zemlin M. Neonatal Morbidity and Mortality in Advanced Aged Mothers-Maternal Age Is Not an Independent Risk Factor for Infants Born Very Preterm. Front Pediatr 2021; 9:747203. [PMID: 34869105 PMCID: PMC8634642 DOI: 10.3389/fped.2021.747203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/20/2021] [Indexed: 12/02/2022] Open
Abstract
Background: As childbearing is postponed in developed countries, maternal age (MA) has increased over decades with an increasing number of pregnancies between age 35-39 and beyond. The aim of the study was to determine the influence of advanced (AMA) and very advanced maternal age (vAMA) on morbidity and mortality of very preterm (VPT) infants. Methods: This was a population-based cohort study including infants from the "Effective Perinatal Intensive Care in Europe" (EPICE) cohort. The EPICE database contains data of 10329 VPT infants of 8,928 mothers, including stillbirths and terminations of pregnancy. Births occurred in 19 regions in 11 European countries. The study included 7,607 live born infants without severe congenital anomalies. The principal exposure variable was MA at delivery. Infants were divided into three groups [reference 18-34 years, AMA 35-39 years and very(v) AMA ≥40 years]. Infant mortality was defined as in-hospital death before discharge home or into long-term pediatric care. The secondary outcome included a composite of mortality and/or any one of the following major neonatal morbidities: (1) moderate-to-severe bronchopulmonary dysplasia; (2) severe brain injury defined as intraventricular hemorrhage and/or cystic periventricular leukomalacia; (3) severe retinopathy of prematurity; and (4) severe necrotizing enterocolitis. Results: There was no significant difference between MA groups regarding the use of surfactant therapy, postnatal corticosteroids, rate of neonatal sepsis or PDA that needed pharmacological or surgical intervention. Infants of AMA/vAMA mothers required significantly less mechanical ventilation during NICU stay than infants born to non-AMA mothers, but there was no significant difference in length of mechanical ventilation and after stratification by gestational age group. Adverse neonatal outcomes in VPT infants born to AMA/vAMA mothers did not differ from infants born to mothers below the age of 35. Maternal age showed no influence on mortality in live-born VPT infants. Conclusion: Although AMA/vAMA mothers encountered greater pregnancy risk, the mortality and morbidity of VPT infants was independent of maternal age.
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Affiliation(s)
- Nasenien Nourkami-Tutdibi
- Saarland University Medical Center, Hospital for General Pediatrics and Neonatology, Homburg, Germany
| | - Erol Tutdibi
- Saarland University Medical Center, Hospital for General Pediatrics and Neonatology, Homburg, Germany
| | - Theresa Faas
- Saarland University Medical Center, Hospital for General Pediatrics and Neonatology, Homburg, Germany
| | - Gudrun Wagenpfeil
- Saarland University Medical Center, Institute of Medical Biometry, Epidemiology and Medical Informatics, Homburg, Germany
| | - Elizabeth S Draper
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Samantha Johnson
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Marina Cuttini
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rym El Rafei
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
| | - Anna-Veera Seppänen
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
| | - Jan Mazela
- Department of Neonatology and Neonatal Infectious Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Rolf Felix Maier
- Children's Hospital, University Hospital, Philipps University Marburg, Marburg, Germany
| | | | - Henrique Barros
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
| | - Carina Rodrigues
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
| | - Jennifer Zeitlin
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
| | - Michael Zemlin
- Saarland University Medical Center, Hospital for General Pediatrics and Neonatology, Homburg, Germany
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Abstract
The premature infant is born into the world unprepared to naturally thrive in a foreign environment. Lung development entails immense growth, structural remodeling and differentiation of specialized cells during the normal term perinatal and postnatal periods. Thus, the premature infant presents with a lung deficient for appropriate respiration. Disruption of lung development seen in bronchopulmonary dysplasia (BPD) and chronic lung disease (CLD) results in not only impaired airway growth but also a deficiency in the accompanying vasculature including the capillary system required for gas exchange. Deficient vascular area can lead to elevated pulmonary vascular resistance and the development of pulmonary hypertension (PH). Unlike PH seen in children and adults with pulmonary arterial hypertension (PAH), treatment with conventional pulmonary vasodilators can be limited in developmental lung disease-associated PH because there are fewer blood vessels to dilate. In this brief review, we highlight some of the knowledge on PH in the premature infant presented at the Proceedings of the 22nd Annual Update on Pediatric and Congenital Cardiovascular Disease.
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Affiliation(s)
- Lori A Christ
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer M Sucre
- Mildred Stahlman Division of Neonatology, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - David B Frank
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.,Penn-CHOP Lung Biology Institute and Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA
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Torchin H, Morgan AS, Ancel PY. International comparisons of neurodevelopmental outcomes in infants born very preterm. Semin Fetal Neonatal Med 2020; 25:101109. [PMID: 32354556 DOI: 10.1016/j.siny.2020.101109] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We summarise rates of survival and neurodevelopmental impairment in very (<32 weeks' gestation) and extremely (<28 weeks' gestation) preterm infants using data from recent meta-analyses. Methodological issues that require consideration when comparing international data are highlighted using examples of population-based or multi-centre cohorts of children born extremely preterm. The impact of baseline population, outcome definition, gestational age assessment, age at neurodevelopmental assessment, year of birth and follow-up rates are discussed. The impact of the intensity of perinatal care and of post-discharge management on survival and neurodevelopmental outcomes is also discussed. There is a future need for harmonisation of data collection and for more accurate and standardised reporting of neurodevelopmental outcomes in very preterm children.
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Affiliation(s)
- Héloïse Torchin
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France; Department of Neonatal Medicine, Cochin-Port Royal Hospital, AP-HP, Paris, F-75014, France.
| | - Andreï S Morgan
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France; Elizabeth Garrett Anderson Institute for Womens' Health, UCL, 74 Huntley Street, London, WC1E 6AU, UK; SAMU 93 - SMUR Pédiatrique, CHI André Grégoire, Groupe Hospitalier Universitaire Paris Seine-Saint-Denis, Assistance Publique des Hôpitaux de Paris, Montreuil, France.
| | - Pierre-Yves Ancel
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, F-75004, Paris, France; Clinical Research Unit, Centre for Clinical Investigation P1419, APHP.CUP, F-75014, Paris, France.
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7
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Brumbaugh JE, Hansen NI, Bell EF, Sridhar A, Carlo WA, Hintz SR, Vohr BR, Colaizy TT, Duncan AF, Wyckoff MH, Baack ML, Rysavy MA, DeMauro SB, Stoll BJ, Das A, Higgins RD. Outcomes of Extremely Preterm Infants With Birth Weight Less Than 400 g. JAMA Pediatr 2019; 173:434-445. [PMID: 30907941 PMCID: PMC6503635 DOI: 10.1001/jamapediatrics.2019.0180] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Birth weight (BW) is an important predictor of mortality and morbidity. At extremely early gestational ages (GAs), BW may influence decisions regarding initiation of resuscitation. OBJECTIVE To characterize outcomes of liveborn infants with a BW less than 400 g. DESIGN, SETTING, AND PARTICIPANTS This retrospective multicenter cohort study analyzed extremely preterm infants born between January 2008 and December 2016 within the National Institute of Child Health and Human Development Neonatal Research Network. Infants with a BW less than 400 g and a GA of 22 to 26 weeks were included. Active treatment was defined as the provision of any potentially lifesaving intervention after birth. Survival was analyzed for the entire cohort; neurodevelopmental impairment (NDI) was examined for those born between January 2008 and December 2015 (birth years with outcomes available for analysis). Neurodevelopmental impairment at 18 to 26 months' corrected age (CA) was defined as a Bayley Scales of Infant and Toddler Development, Third Edition, cognitive composite score less than 85, a motor composite score less than 85, moderate or severe cerebral palsy, gross motor function classification system score of 2 or greater, bilateral blindness, and/or hearing impairment. Data were analyzed from September 2017 to October 2018. EXPOSURES Birth weight less than 400 g. MAIN OUTCOMES AND MEASURES The primary outcome was survival to discharge among infants who received active treatment. Analysis of follow-up data was limited to infants born from 2008 to 2015 to ensure children had reached assessment age. Within this cohort, neurodevelopmental outcomes were assessed for infants who survived to 18 to 26 months' CA and returned for a comprehensive visit. RESULTS Of the 205 included infants, 121 (59.0%) were female, 133 (64.9%) were singletons, and 178 (86.8%) were small for gestational age. Almost half (101 of 205 [49.3%]) received active treatment at birth. A total of 26 of 205 infants (12.7%; 95% CI, 8.5-18.9) overall survived to discharge, and 26 of 101 actively treated infants (25.7%; 95% CI, 17.6-35.4) survived to discharge. Within the subset of infants with a BW less than 400 g and a GA of 22 to 23 weeks, 6 of 36 actively treated infants (17%; 95% CI, 6-33) survived to discharge. Among infants born between 2008 and 2015, 23 of 90 actively treated infants (26%; 95% CI, 17-36) survived to discharge. Two infants died after discharge, and 2 were lost to follow-up. Thus, 19 of 90 actively treated infants (21%; 95% CI, 13-31) were evaluated at 18 to 26 months' CA. Moderate or severe NDI occurred in 14 of 19 infants (74%). CONCLUSIONS AND RELEVANCE Infants born with a BW less than 400 g are at high risk of mortality and significant morbidity. Although 21% of infants survived to 18 to 26 months' CA with active treatment, NDI was common among survivors.
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Affiliation(s)
- Jane E. Brumbaugh
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nellie I. Hansen
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | | | - Amaanti Sridhar
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | | | - Susan R. Hintz
- Department of Pediatrics, Stanford University, Palo Alto, California
| | - Betty R. Vohr
- Department of Pediatrics, Brown University, Providence, Rhode Island
| | | | - Andrea F. Duncan
- Department of Pediatrics, University of Texas Health Science Center at Houston
| | - Myra H. Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Michelle L. Baack
- Children’s Health Research Center, Sanford Research, Sioux Falls, South Dakota
| | | | - Sara B. DeMauro
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| | - Barbara J. Stoll
- Department of Pediatrics, University of Texas Health Science Center at Houston
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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8
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Adams M, Berger TM, Borradori-Tolsa C, Bickle-Graz M, Grunt S, Gerull R, Bassler D, Natalucci G. Association between perinatal interventional activity and 2-year outcome of Swiss extremely preterm born infants: a population-based cohort study. BMJ Open 2019; 9:e024560. [PMID: 30878980 PMCID: PMC6429852 DOI: 10.1136/bmjopen-2018-024560] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To investigate if centre-specific levels of perinatal interventional activity were associated with neonatal and neurodevelopmental outcome at 2 years of age in two separately analysed cohorts of infants: cohort A born at 22-25 and cohort B born at 26-27 gestational weeks, respectively. DESIGN Geographically defined, retrospective cohort study. SETTING All nine level III perinatal centres (neonatal intensive care units and affiliated obstetrical services) in Switzerland. PATIENTS All live-born infants in Switzerland in 2006-2013 below 28 gestational weeks, excluding infants with major congenital malformation. OUTCOME MEASURES Outcomes at 2 years corrected for prematurity were mortality, survival with any major neonatal morbidity and with severe-to-moderate neurodevelopmental impairment (NDI). RESULTS Cohort A associated birth in a centre with high perinatal activity with low mortality adjusted OR (aOR 0.22; 95% CI 0.16 to 0.32), while no association was observed with survival with major morbidity (aOR 0.74; 95% CI 0.46 to 1.19) and with NDI (aOR 0.97; 95% CI 0.46 to 2.02). Median age at death (8 vs 4 days) and length of stay (100 vs 73 days) were higher in high than in low activity centres. The results for cohort B mirrored those for cohort A. CONCLUSIONS Centres with high perinatal activity in Switzerland have a significantly lower risk for mortality while having comparable outcomes among survivors. This confirms the results of other studies but in a geographically defined area applying a more restrictive approach to initiation of perinatal intensive care than previous studies. The study adds that infants up to 28 weeks benefited from a higher perinatal activity and why further research is required to better estimate the added burden on children who ultimately do not survive.
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Affiliation(s)
- Mark Adams
- Department of Neonatology, Universitätsspital Zürich, Zürich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute, University Zürich, Zürich, Schweiz, Switzerland
| | - Thomas M Berger
- Neonatal and Paediatric Intensive Care Unit, Kinderspital Luzern, Luzern, Switzerland
| | | | - Myriam Bickle-Graz
- Department Woman-Mother-Child, University Hospital Lausanne, Lausanne, Switzerland
| | - Sebastian Grunt
- Division of Neuropaediatrics, Development and Rehabilitation, Children’s University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Roland Gerull
- Department of Neonatology, University of Basel Children’s Hospital (UKBB), Basel, Switzerland
| | - Dirk Bassler
- Department of Neonatology, Universitätsspital Zürich, Zürich, Switzerland
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9
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Diguisto C, Foix L'Helias L, Morgan AS, Ancel PY, Kayem G, Kaminski M, Perrotin F, Khoshnood B, Goffinet F. Neonatal Outcomes in Extremely Preterm Newborns Admitted to Intensive Care after No Active Antenatal Management: A Population-Based Cohort Study. J Pediatr 2018; 203:150-155. [PMID: 30270165 DOI: 10.1016/j.jpeds.2018.07.072] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 06/06/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate the association between active antenatal management and neonatal outcomes in extremely preterm newborns admitted to a neonatal intensive care unit (NICU). STUDY DESIGN This population-based cohort study was conducted in 25 regions of France. Infants born in 2011 between 220/7 and 266/7 weeks of gestation and admitted to a NICU were included. Infants with lethal congenital malformations or death in the delivery room were excluded. A multilevel multivariable analysis was performed, accounting for clustering by mother (multiple pregnancies) and hospital plus individual characteristics, to estimate the association between the main exposure of no active antenatal management (not receiving antenatal corticosteroids, magnesium sulfate, or cesarean delivery for fetal indications) and a composite outcome of death or severe neonatal morbidity (including severe forms of brain or lung injury, retinopathy of prematurity, and necrotizing enterocolitis). RESULTS Among 3046 extremely preterm births, 783 infants were admitted to a NICU. Of these, 138 (18%) did not receive active antenatal management. The risk of death or severe morbidity was significantly higher for infants without active antenatal management (crude OR, 2.60; 95% CI, 1.44-4.66). This finding persisted after adjustment for gestational age (OR, 2.08; 95% CI, 1.19-3.62) and all confounding factors (OR, 1.86; 95% CI, 1.09-3.20). CONCLUSIONS The increased risk of severe neonatal outcomes for extremely preterm babies admitted to a NICU without optimal antenatal management should be considered in individual-level decision making and in the development of professional guidelines for the management of extremely preterm births.
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Affiliation(s)
- Caroline Diguisto
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France; Maternité Olympe de Gouges, Regional Univeristy Hospital, François Rabelais University, Tours, France.
| | - Laurence Foix L'Helias
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France; Service de Néonatologie Hopital Armand Trousseau, APHP, Pierre et Marie Curie University, Paris, France
| | - Andrei S Morgan
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France; Institute for Women's Health, University College London, London, United Kingdom
| | - Pierre-Yves Ancel
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France; URC CIC P1419, DHU Risk in Pregnancy, Cochin Hotel Dieu Hopital APHP, Paris, France
| | - Gilles Kayem
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France; Service de Gynécologie Obstétrique, Trousseau, APHP, Pierre et Marie Curie University, Paris, France
| | - Monique Kaminski
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Franck Perrotin
- Maternité Olympe de Gouges, Regional Univeristy Hospital, François Rabelais University, Tours, France
| | - Babak Khoshnood
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Francois Goffinet
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France; Maternity Unit of Port Royal, Paris Descartes University, Cochin Broca Hotel Dieu Hospitals, DHU Risk in Pregnancy, Cochin Hotel Dieu University Hospital, Assistance Publique des Hopitaux de Paris, Paris, France
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10
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Smith LK, Morisaki N, Morken NH, Gissler M, Deb-Rinker P, Rouleau J, Hakansson S, Kramer MR, Kramer MS. An International Comparison of Death Classification at 22 to 25 Weeks' Gestational Age. Pediatrics 2018; 142:peds.2017-3324. [PMID: 29899042 DOI: 10.1542/peds.2017-3324] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To explore international differences in the classification of births at extremely low gestation and the subsequent impact on the calculation of survival rates. METHODS We used national data on births at 22 to 25 weeks' gestation from the United States (2014; n = 11 144), Canada (2009-2014; n = 5668), the United Kingdom (2014-2015; n = 2992), Norway (2010-2014; n = 409), Finland (2010-2015; n = 348), Sweden (2011-2014; n = 489), and Japan (2014-2015; n = 2288) to compare neonatal survival rates using different denominators: all births, births alive at the onset of labor, live births, live births surviving to 1 hour, and live births surviving to 24 hours. RESULTS For births at 22 weeks' gestation, neonatal survival rates for which we used live births as the denominator varied from 3.7% to 56.7% among the 7 countries. This variation decreased when the denominator was changed to include stillbirths (ie, all births [1.8%-22.3%] and fetuses alive at the onset of labor [3.7%-38.2%]) or exclude early deaths and limited to births surviving at least 12 hours (50.0%-77.8%). Similar trends were seen for infants born at 23 weeks' gestation. Variation diminished considerably at 24 and 25 weeks' gestation. CONCLUSIONS International variation in neonatal survival rates at 22 to 23 weeks' gestation diminished considerably when including stillbirths in the denominator, revealing the variation arises in part from differences in the proportion of births reported as live births, which itself is closely connected to the provision of active care.
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Affiliation(s)
- Lucy K Smith
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Naho Morisaki
- National Center for Child Health and Development, Tokyo, Japan;
| | - Nils-Halvdan Morken
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Mika Gissler
- National Institute for Health and Welfare, Helsinki, Finland
| | | | | | | | - Michael R Kramer
- Department of Epidemiology, Emory University, Atlanta, Georgia; and
| | - Michael S Kramer
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
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11
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Atwell K, Callander E, Lindsay D, Marshall PB, Morris SA. Selection Bias and Outcomes for Preterm Neonates. Pediatrics 2018:1. [PMID: 29921737 DOI: 10.1542/peds.2018-0470] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Reported survival and neurodevelopmental outcomes at 23 weeks' gestation are based on the infants admitted to NICUs. In this study, we aim to describe the association between clinical characteristics and admission to NICU at 23, 24 and 25 weeks' gestation. METHODS Cohort data from 2 national databases enabled comparison of the clinical characteristics all Australian births and all NICU admissions during 2010-2013 at 23, 24, and 25 weeks' gestation. RESULTS NICU admission occurred in 15% of all births at 23 weeks, in comparison with 49% at 24 weeks and 64% at 25 weeks. At 23 weeks, live-born infants were less likely to be admitted to NICU with birth weight <500 g compared with >500 g (13% vs 43%, P < .0001), and boys were admitted less compared with girls (33% vs 43%, P < .018). In contrast, birth weight (including birth weight <500 g) and sex had little or no impact on NICU admission at 24 and 25 weeks. Only 8% of live births were born by caesarean delivery at 23 weeks compared with 33% at 24 weeks and 48% at 25 weeks' gestation. CONCLUSIONS In the Australian population, admission to the NICU is more likely to be influenced by birth weight and sex at 23 weeks' gestation when compared with 24 and 25 weeks' gestation. Survival outcomes at 23 weeks may be affected by less active perinatal care. Uncertainty exists regarding the generalizability of current data regarding survival and developmental potential of live-born 23-week infants.
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Affiliation(s)
- Kerryn Atwell
- Neonatal Unit, Flinders Medical Centre, Adelaide, Australia; .,College of Public Health and Tropical Medicine and
| | - Emily Callander
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Australia; and
| | | | - Peter Blake Marshall
- Neonatal Unit, Flinders Medical Centre, Adelaide, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Scott Adam Morris
- Neonatal Unit, Flinders Medical Centre, Adelaide, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, Australia
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12
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Morisaki N, Isayama T, Samura O, Wada K, Kusuda S. Socioeconomic inequity in survival for deliveries at 22-24 weeks of gestation. Arch Dis Child Fetal Neonatal Ed 2018; 103:F202-F207. [PMID: 28847870 DOI: 10.1136/archdischild-2017-312635] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 06/27/2017] [Accepted: 07/31/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Guidelines recommend individual decision making on resuscitating infants of 22-24 weeks' gestational age (GA) at birth. When the decision not to resuscitate is made, infants would likely die soon after delivery, and under some circumstances such neonatal deaths may be registered as stillbirths occurring during delivery (intrapartum stillbirth). Thus we assessed whether socioeconomic factors are associated with peridelivery deaths (during or within 1 hour of delivery) of infants delivered at 22-24 weeks' gestation. METHODS We analysed 14 726 singletons of 22-24 weeks' GA using the 2003-2011 Japanese vital statistics, and assessed how maternal characteristics influence risk of peridelivery death as well as intrauterine fetal death (IUFD) and death after 1 hour of age until 40 weeks postmenstrual age. RESULTS Living in a municipality with low-average income (lowest tertile (risk ratio 1.32, 95% CI 1.20 to 1.44), middle tertile (risk ratio 1.08, 95% CI 0.98 to 1.19)), younger maternal age (age <20 (risk ratio 1.43, 95% CI 1.17 to 1.75), age 20-34 (risk ratio 1.14, 95% CI 1.03 to 1.27)) and having previous live births (risk ratio 1.08, 95% CI 1.01 to 1.17) increased risk of peridelivery deaths, but did not increase risk of IUFD or deaths after 1 hour of age. Peridelivery death was twice as likely to occur in births to multiparous teenage mothers in a low-income municipality, compared with those of older primiparous mothers in a wealthier municipality. CONCLUSIONS Socioeconomic factors substantially influence whether births of 22-24 weeks' GA survive delivery and the first hour of life. Such disparities may reflect the impact of socioeconomic situations on decision making for resuscitation.
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Affiliation(s)
- Naho Morisaki
- Division of Life-Course Epidemiology, Department of Social Medicine, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Tetsuya Isayama
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.,Division of Neonatology, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Osamu Samura
- Department of Obstetrics and Gynecology, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Kazuko Wada
- Department of Neonatal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Satoshi Kusuda
- Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
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13
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Hwang JS, Rehan VK. Recent Advances in Bronchopulmonary Dysplasia: Pathophysiology, Prevention, and Treatment. Lung 2018; 196:129-138. [PMID: 29374791 DOI: 10.1007/s00408-018-0084-z] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 01/04/2018] [Indexed: 12/16/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is potentially one of the most devastating conditions in premature infants with longstanding consequences involving multiple organ systems including adverse effects on pulmonary function and neurodevelopmental outcome. Here we review recent studies in the field to summarize the progress made in understanding in the pathophysiology, prognosis, prevention, and treatment of BPD in the last decade. The work reviewed includes the progress in understanding its pathobiology, genomic studies, ventilatory strategies, outcomes, and therapeutic interventions. We expect that this review will help guide clinicians to treat premature infants at risk for BPD better and lead researchers to initiate further studies in the field.
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Affiliation(s)
- Jung S Hwang
- Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, 1124 West Carson Street, Torrance, CA, 90502, USA
| | - Virender K Rehan
- Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, 1124 West Carson Street, Torrance, CA, 90502, USA.
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14
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Diguisto C, Goffinet F, Lorthe E, Kayem G, Roze JC, Boileau P, Khoshnood B, Benhammou V, Langer B, Sentilhes L, Subtil D, Azria E, Kaminski M, Ancel PY, Foix-L'Hélias L. Providing active antenatal care depends on the place of birth for extremely preterm births: the EPIPAGE 2 cohort study. Arch Dis Child Fetal Neonatal Ed 2017; 102:F476-F482. [PMID: 28667191 DOI: 10.1136/archdischild-2016-312322] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 04/29/2017] [Accepted: 05/02/2017] [Indexed: 11/03/2022]
Abstract
UNLABELLED Survival rates of infants born before 25 weeks of gestation are low in France and have not improved over the past decade. Active perinatal care increases these infants' likelihood of survival. OBJECTIVE Our aim was to identify factors associated with active antenatal care, which is the first step of proactive perinatal care in extremely preterm births. METHODS The population included 1020 singleton births between 220/6 and 260/6 weeks of gestation enrolled in the Etude Epidémiologique sur les Petits Ages Gestationnels 2 study, a French national population-based cohort of very preterm infants born in 2011. The main outcome was 'active antenatal care' defined as the administration of either corticosteroids or magnesium sulfate or delivery by caesarean section for fetal rescue. A multivariable analysis was performed using a two-level multilevel model taking into account the maternity unit of delivery to estimate the adjusted ORs (aORs) of receiving active antenatal care associated with maternal, obstetric and place of birth characteristics. RESULTS Among the population of extremely preterm births, 42% received active antenatal care. After standardisation for gestational age, regional rates of active antenatal care varied between 22% (95% CI 5% to 38%) and 61% (95% CI 44% to 78%). Despite adjustment for individual and organisational characteristics, active antenatal care varied significantly between maternity units (p=0.03). Rates of active antenatal care increased with gestational age with an aOR of 6.46 (95% CI 3.40 to 12.27) and 10.09 (95% CI 5.26 to 19.36) for infants born at 25 and 26 weeks' gestation compared with those born at 24 weeks. No other individual characteristic was associated with active antenatal care. CONCLUSION Even after standardisation for gestational age, active antenatal care in France for extremely preterm births varies widely with place of birth. The dependence of life and death decisions on place of birth raises serious ethical questions.
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Affiliation(s)
- Caroline Diguisto
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,Maternité Olympe de Gouges, Centre Hospitalier Regional Universitaire Tours, Tours, France.,Université François Rabelais, Tours, France
| | - François Goffinet
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,DHU Risk in Pregnancy, Maternité Port Royal Paris Descartes University Cochin Broca Hotel Dieu Hospitals Assistance publique des hopitaux de Paris, Paris, France
| | - Elsa Lorthe
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,UPMC Univ Paris 06, Sorbonne Universités, Paris, France
| | - Gilles Kayem
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,UPMC Univ Paris 06, Sorbonne Universités, Paris, France.,Service de Gynécologie Obstétrique, Paris, France
| | - Jean-Christophe Roze
- Service de Néonatologie, CIC 004, INSERM, Nantes University Hospital, Nantes, France
| | - Pascal Boileau
- Service de Néonatologie, CHI Poissy St-Germain-en-Laye, University Versailles StQuentin-en-Yvelines, Versailles, France
| | - Babak Khoshnood
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Valérie Benhammou
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Bruno Langer
- Pole de Gynécologie Obstétrique, Hôpital de Hautepierre, Strasbourg, France
| | - Loic Sentilhes
- Department of Obstetrics and Gynecology, University Hospital Bordeaux, Bordeaux, France
| | - Damien Subtil
- Hôpital Jeanne de Flandre, CHRU-University, Lille Nord, France
| | - Elie Azria
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,Maternité Notre Dame de Bon Secours, Groupe Hospitalier Paris Saint Joseph, ParisDescartes University, DHU Risk in Pregnancy, Paris, France
| | - Monique Kaminski
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Pierre-Yves Ancel
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,URC CIC P1419, DHU Risk in Pregnancy, Cochin Hotel Dieu Hopital APHP, Paris, France
| | - Laurence Foix-L'Hélias
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,UPMC Univ Paris 06, Sorbonne Universités, Paris, France.,Service de Néonatologie, Hopital Armand Trousseau, APHP, Paris, France
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15
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Bonet M, Cuttini M, Piedvache A, Boyle EM, Jarreau PH, Kollée L, Maier RF, Milligan D, Van Reempts P, Weber T, Barros H, Gadzinowki J, Draper ES, Zeitlin J. Changes in management policies for extremely preterm births and neonatal outcomes from 2003 to 2012: two population-based studies in ten European regions. BJOG 2017; 124:1595-1604. [PMID: 28294506 DOI: 10.1111/1471-0528.14639] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate changes in maternity and neonatal unit policies towards extremely preterm infants (EPTIs) between 2003 and 2012, and concurrent trends in their mortality and morbidity in ten European regions. DESIGN Population-based cohort studies in 2003 (MOSAIC study) and 2011/2012 (EPICE study) and questionnaires from hospitals. SETTING 70 hospitals in ten European regions. POPULATION Infants born at <27 weeks of gestational age (GA) in hospitals participating in both the MOSAIC and EPICE studies (1240 in 2003, 1293 in 2011/2012). METHODS We used McNemar's Chi2 test, paired t-tests and conditional logistic regression for comparisons over time. MAIN OUTCOMES MEASURES Reported policies, mortality and morbidity of EPTIs. RESULTS The lowest GA at which maternity units reported performing a caesarean section for acute distress of a singleton non-malformed fetus decreased from an average of 24.7 to 24.1 weeks (P < 0.01) when parents were in favour of active management, and 26.1 to 25.2 weeks (P = 0.01) when parents were against. Units reported that neonatologists were called more often for spontaneous deliveries starting at 22 weeks GA in 2012 and more often made decisions about active resuscitation alone, rather than in multidisciplinary teams. In-hospital mortality after live birth for EPTIs decreased from 50% to 42% (P < 0.01). Units reporting more active management in 2012 than 2003 had higher mortality in 2003 (55% versus 43%; P < 0.01) and experienced larger declines (55 to 44%; P < 0.001) than units where policies stayed the same (43 to 37%; P = 0.1). CONCLUSIONS European hospitals reporting changes in management policies experienced larger survival gains for EPTIs. TWEETABLE ABSTRACT Changes in reported policies for management of extremely preterm births were related to mortality declines.
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Affiliation(s)
- M Bonet
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - M Cuttini
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - A Piedvache
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - E M Boyle
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - P H Jarreau
- Service de Médecine et Réanimation néonatales de Port-Royal, DHU Risks in Pregnancy, Université Paris Descartes and Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaire Paris Centre Site Cochin, Paris, France
| | - L Kollée
- Department of Neonatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - R F Maier
- Children's Hospital, University Hospital, Philipps University Marburg, Marburg, Germany
| | - Dwa Milligan
- University of Newcastle, Newcastle-upon-Tyne, UK
| | - P Van Reempts
- Department of Neonatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium.,Study Centre for Perinatal Epidemiology Flanders, Brussels, Belgium
| | - T Weber
- Department of Obstetrics, Hvidovre University Hospital, Hvidovre, Denmark
| | - H Barros
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
| | - J Gadzinowki
- Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
| | - E S Draper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - J Zeitlin
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
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16
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Draper ES, Manktelow BN, Cuttini M, Maier RF, Fenton AC, Van Reempts P, Bonamy AK, Mazela J, Bᴓrch K, Koopman-Esseboom C, Varendi H, Barros H, Zeitlin JJ. Variability in Very Preterm Stillbirth and In-Hospital Mortality Across Europe. Pediatrics 2017; 139:peds.2016-1990. [PMID: 28341800 DOI: 10.1542/peds.2016-1990] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Stillbirth and in-hospital mortality rates associated with very preterm births (VPT) vary widely across Europe. International comparisons are complicated by a lack of standardized data collection and differences in definitions, registration, and reporting. This study aims to determine what proportion of the variation in stillbirth and in-hospital VPT mortality rates persists after adjusting for population demographics, case-mix, and timing of death. METHODS Standardized data collection for a geographically defined prospective cohort of VPTs (22+0-31+6 weeks gestation) across 16 regions in Europe. Crude and adjusted stillbirth and in-hospital mortality rates for VPT infants were calculated by time of death by using multinomial logistic regression models. RESULTS The stillbirth and in-hospital mortality rate for VPTs was 27.7% (range, 19.9%-35.9% by region). Adjusting for maternal and pregnancy characteristics had little impact on the variation. The addition of infant characteristics reduced the variation of mortality rates by approximately one-fifth (4.8% to 3.9%). The SD for deaths <12 hours after birth was reduced by one-quarter, but did not change after risk adjustment for deaths ≥12 hours after birth. CONCLUSIONS In terms of the regional variation in overall VPT mortality, over four-fifths of the variation could not be accounted for by maternal, pregnancy, and infant characteristics. Investigation of the timing of death showed that these characteristics only accounted for a small proportion of the variation in VPT deaths. These findings suggest that there may be an inequity in the quality of care provision and treatment of VPT infants across Europe.
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Affiliation(s)
- Elizabeth S Draper
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom;
| | - Bradley N Manktelow
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Marina Cuttini
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, Rome, Italy
| | - Rolf F Maier
- Children's Hospital, University Hospital, Philipps University Marburg, Marburg, Germany
| | - Alan C Fenton
- Newcastle Neonatal Services, Royal Victoria Infirmary, Newcastle, United Kingdom
| | - Patrick Van Reempts
- Department of Neonatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium.,Flemish Study Centre for Perinatal Epidemiology, Brussels, Belgium
| | - Anna-Karin Bonamy
- Departments of Medicine Solna and.,Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Jan Mazela
- Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Klaus Bᴓrch
- Department of Neonatology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Corinne Koopman-Esseboom
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Heili Varendi
- Department of Pediatrics, University of Tartu, Tartu University Hospital, Tartu, Estonia
| | - Henrique Barros
- EPIUnit Institute of Public Health, University of Porto, Porto, Portugal; and
| | - Jennifer J Zeitlin
- INSERM, Obstetrical, Perinatal and Paediatric Epidemiology Research Team, Centre for Epidemiology and Biostatistics (U1153), Paris-Descartes University, Paris, France
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17
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Monier I, Ancel PY, Ego A, Guellec I, Jarreau PH, Kaminski M, Goffinet F, Zeitlin J. Gestational age at diagnosis of early-onset fetal growth restriction and impact on management and survival: a population-based cohort study. BJOG 2017; 124:1899-1906. [DOI: 10.1111/1471-0528.14555] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2016] [Indexed: 12/01/2022]
Affiliation(s)
- I Monier
- Inserm UMR 1153; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Paris Descartes University; Paris France
- Antoine Beclere Maternity Unit; Department of Obstetrics and Gynaecology; South Paris University Hospitals; AP-HP; Paris France
| | - P-Y Ancel
- Inserm UMR 1153; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Paris Descartes University; Paris France
| | - A Ego
- Inserm UMR 1153; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Paris Descartes University; Paris France
- Clinical Research Centre (CICO3); Grenoble University Hospital; Grenoble France
| | - I Guellec
- Inserm UMR 1153; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Paris Descartes University; Paris France
- Paediatric and Neonatal Intensive Care Unit; Armand-Trousseau Hospital; AP-HP; Paris France
| | - P-H Jarreau
- Department of Neonatal Medicine and Intensive Care Unit of Port-Royal; Cochin University Hospital; AP-HP; DHU Risks in Pregnancy; Paris France
| | - M Kaminski
- Inserm UMR 1153; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Paris Descartes University; Paris France
| | - F Goffinet
- Inserm UMR 1153; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Paris Descartes University; Paris France
- Port-Royal Maternity Unit; Department of Obstetrics and Gynaecology; Cochin University Hospital; AP-HP; Paris France
| | - J Zeitlin
- Inserm UMR 1153; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Paris Descartes University; Paris France
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Hesselman S, Jonsson M, Råssjö EB, Windling M, Högberg U. Maternal complications in settings where two-thirds of extremely preterm births are delivered by cesarean section. J Perinat Med 2017; 45:121-127. [PMID: 27768584 DOI: 10.1515/jpm-2016-0198] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 09/29/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate the maternal complications associated with cesarean section (CS) in the extremely preterm period according to the gestational week (GW) and to indication of delivery. STUDY DESIGN This is a retrospective case-referent study with a review of medical records of women who delivered at 22-27 weeks of gestation (n=647) at two level III units in Sweden. For abdominal delivery, gestational length was stratified into 22-24 (n=105) and 25-27 (n=301) weeks. For comparison, data on women who underwent a CS at term were identified in a register-based database. RESULTS The rate of CS in extremely preterm births was 62.8%. There was no difference in the complication rates, but types of incisions other than the low transverse incision were required more often at 22-24 (18.1%) weeks than at 25-27 GWs (9.6%) (P=0.02). Major maternal complications occurred in 6.6% compared with 2.1% in the extremely preterm and term CS, respectively (P<0.01). A maternal indication of extremely preterm CS increased the risk of complications. CONCLUSIONS Almost two-thirds of the births at 22-27 GWs had an abdominal delivery. No increase in short-term morbidity was observed at 22-24 weeks compared to 25-27 weeks. CS performed extremely preterm had more major complications recorded than cesarean at term. The complications are driven by the underlying maternal condition.
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Zegers MJ, Hukkelhoven CWPM, Uiterwaal CSPM, Kollée LAA, Groenendaal F. Changing Dutch approach and trends in short-term outcome of periviable preterms. Arch Dis Child Fetal Neonatal Ed 2016; 101:F391-6. [PMID: 26728314 DOI: 10.1136/archdischild-2015-308803] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 11/30/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND In 2006, the Dutch guideline for active treatment of extremely preterm neonates advised to lower the gestational age threshold for active intervention from 26 0/7 to 25 0/7 weeks gestation. OBJECTIVE To evaluate the association between the guideline modification and early neonatal outcome. DESIGN National cohort study, using prospectively collected data from The Netherlands Perinatal Registry. PATIENTS The study population consisted of 9713 infants with a gestational age between 24 0/7 and 29 6/7 weeks, born between 2000 and 2011. Three gestational age subgroups were analysed: 24 0/7 to 24 6/7 weeks (n=269), 25 0/7 to 25 6/7 weeks (n=852) and 26 0/7 to 29 6/7 weeks (n=8592). MAIN OUTCOME MEASURES Neonatal intensive care unit (NICU) admission, live births, neonatal in-hospital mortality, morbidity and favourable outcome (no mortality or morbidity) before (2000-2005; period 1) and after (2007-2011; period 2) introduction of the modified guideline, using χ(2) tests and univariable and multivariable logistic regression analyses. RESULTS In the second period, the proportion of live births and NICU admissions increased and the proportion of neonatal and in-hospital mortality decreased significantly in all subgroups. Morbidity in surviving infants of 25 weeks increased significantly, although the association between guideline modification and morbidity became non-significant after case-mix adjustment. Overall, favourable outcome did not change significantly after guideline modification in all subgroups when adjusted for variation in case-mix. CONCLUSIONS Overall, the trend in mortality gradually declined at all gestational ages, starting before 2006. This suggests that the guideline modification was a formalisation of already existing daily practice.
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Affiliation(s)
- Maria J Zegers
- Department of Neonatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Cuno S P M Uiterwaal
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | - Louis A A Kollée
- Department of Neonatology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Zeitlin J, Manktelow BN, Piedvache A, Cuttini M, Boyle E, van Heijst A, Gadzinowski J, Van Reempts P, Huusom L, Weber T, Schmidt S, Barros H, Dillalo D, Toome L, Norman M, Blondel B, Bonet M, Draper ES, Maier RF. Use of evidence based practices to improve survival without severe morbidity for very preterm infants: results from the EPICE population based cohort. BMJ 2016; 354:i2976. [PMID: 27381936 PMCID: PMC4933797 DOI: 10.1136/bmj.i2976] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To evaluate the implementation of four high evidence practices for the care of very preterm infants to assess their use and impact in routine clinical practice and whether they constitute a driver for reducing mortality and neonatal morbidity. DESIGN Prospective multinational population based observational study. SETTING 19 regions from 11 European countries covering 850 000 annual births participating in the EPICE (Effective Perinatal Intensive Care in Europe for very preterm births) project. PARTICIPANTS 7336 infants born between 24+0 and 31+6 weeks' gestation in 2011/12 without serious congenital anomalies and surviving to neonatal admission. MAIN OUTCOME MEASURES Combined use of four evidence based practices for infants born before 28 weeks' gestation using an "all or none" approach: delivery in a maternity unit with appropriate level of neonatal care; administration of antenatal corticosteroids; prevention of hypothermia (temperature on admission to neonatal unit ≥36°C); surfactant used within two hours of birth or early nasal continuous positive airway pressure. Infant outcomes were in-hospital mortality, severe neonatal morbidity at discharge, and a composite measure of death or severe morbidity, or both. We modelled associations using risk ratios, with propensity score weighting to account for potential confounding bias. Analyses were adjusted for clustering within delivery hospital. RESULTS Only 58.3% (n=4275) of infants received all evidence based practices for which they were eligible. Infants with low gestational age, growth restriction, low Apgar scores, and who were born on the day of maternal admission to hospital were less likely to receive evidence based care. After adjustment, evidence based care was associated with lower in-hospital mortality (risk ratio 0.72, 95% confidence interval 0.60 to 0.87) and in-hospital mortality or severe morbidity, or both (0.82, 0.73 to 0.92), corresponding to an estimated 18% decrease in all deaths without an increase in severe morbidity if these interventions had been provided to all infants. CONCLUSIONS More comprehensive use of evidence based practices in perinatal medicine could result in considerable gains for very preterm infants, in terms of increased survival without severe morbidity.
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Affiliation(s)
- Jennifer Zeitlin
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, 75014, France
| | | | - Aurelie Piedvache
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, 75014, France
| | - Marina Cuttini
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, Rome, Italy
| | - Elaine Boyle
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Arno van Heijst
- Department of Neonatology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Janusz Gadzinowski
- Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Patrick Van Reempts
- Department of Neonatology, Antwerp University Hospital, Antwerp; and Study Centre for Perinatal Epidemiology, Flanders, Brussels, Belgium
| | - Lene Huusom
- Department of Obstetrics, Hvidovre University Hospital, Hvidovre, Denmark
| | - Tom Weber
- Department of Obstetrics, Hvidovre University Hospital, Hvidovre, Denmark
| | - Stephan Schmidt
- Department of Obstetrics, University Hospital, Philipps University, Marburg, Germany
| | - Henrique Barros
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
| | | | - Liis Toome
- Unit of Neonates and Infants, Tallinn Children's Hospital, Tallinn, Estonia; and University of Tartu, Tartu, Estonia
| | - Mikael Norman
- Department of Clinical Science, Intervention and Technology, Division of Paediatrics, Karolinska Institute, Stockholm, Sweden; and Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Beatrice Blondel
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, 75014, France
| | - Mercedes Bonet
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, 75014, France
| | | | - Rolf F Maier
- Children's Hospital, University Hospital, Philipps University, Marburg Germany
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Boland RA, Davis PG, Dawson JA, Doyle LW. What are we telling the parents of extremely preterm babies? Aust N Z J Obstet Gynaecol 2016; 56:274-81. [DOI: 10.1111/ajo.12448] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 01/13/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Rosemarie Anne Boland
- Murdoch Childrens Research Institute; Parkville Victoria Australia
- Department of Obstetrics and Gynaecology; Royal Women's Hospital; University of Melbourne; Parkville Victoria Australia
- Paediatric Infant Perinatal Emergency Retrieval; Royal Children's Hospital; Parkville Victoria Australia
| | - Peter Graham Davis
- Murdoch Childrens Research Institute; Parkville Victoria Australia
- Department of Obstetrics and Gynaecology; Royal Women's Hospital; University of Melbourne; Parkville Victoria Australia
- Newborn Research Centre; Royal Women's Hospital; Parkville Victoria Australia
| | - Jennifer Anne Dawson
- Murdoch Childrens Research Institute; Parkville Victoria Australia
- Department of Obstetrics and Gynaecology; Royal Women's Hospital; University of Melbourne; Parkville Victoria Australia
- Newborn Research Centre; Royal Women's Hospital; Parkville Victoria Australia
| | - Lex William Doyle
- Murdoch Childrens Research Institute; Parkville Victoria Australia
- Department of Obstetrics and Gynaecology; Royal Women's Hospital; University of Melbourne; Parkville Victoria Australia
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Abstract
OBJECTIVE To evaluate in-hospital survival, survival without major morbidity, and neurodevelopmental impairment for neonates born at 23 weeks of gestation provided proactive, coordinated, and comprehensive perinatal and neonatal management. METHODS This was a retrospective cohort study conducted at a single, tertiary care center between 2004 and 2013. Enrollment was limited to mother-neonate dyads at 23 weeks of gestation who were provided a proactive approach defined as documented evidence of antenatal corticosteroid administration, willingness to provide cesarean delivery for fetal distress, and neonatal resuscitation and intensive care. Among survivors, major morbidities (predischarge) and neurodevelopmental assessments at corrected ages of 18-22 months were examined. RESULTS Among 152 live births identified, 101 neonates received proactive care, of whom 60 (59%) survived to hospital discharge. Preterm premature rupture of membranes (adjusted odds ratio [OR] 0.29, 95% confidence interval [CI] 0.09-0.94), fetal growth restriction (OR 0.16, 95% CI 0.03-0.89), delivery room cardiopulmonary resuscitation (OR 0.07, 95% CI 0.02-0.32), and prolonged intubation sequence (OR 0.15, 95% CI 0.05-0.45) were associated with lower neonatal survival. Among neonatal intensive care unit survivors, 62% had at least one major morbidity. Among 50 survivors with assessment at 18-22 months, six (12%) were unimpaired, 20 (40%) had mild impairment, and 24 (48%) had moderate or severe neurodevelopmental impairment. CONCLUSION Proactive, interdisciplinary care enabled more than half of the neonates born at 23 weeks of gestation to survive, and approximately half of children evaluated at 18 months exhibited no or mild impairment. This information should be considered when providing prognostic advice to families with threatened preterm birth at 23 weeks of gestation. LEVEL OF EVIDENCE II.
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Azria E, Kayem G, Langer B, Marchand-Martin L, Marret S, Fresson J, Pierrat V, Arnaud C, Goffinet F, Kaminski M, Ancel PY. Neonatal Mortality and Long-Term Outcome of Infants Born between 27 and 32 Weeks of Gestational Age in Breech Presentation: The EPIPAGE Cohort Study. PLoS One 2016; 11:e0145768. [PMID: 26744838 PMCID: PMC4706444 DOI: 10.1371/journal.pone.0145768] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 12/08/2015] [Indexed: 01/21/2023] Open
Abstract
Objective To determine whether breech presentation is an independent risk factor for neonatal morbidity, mortality, or long-term neurologic morbidity in very preterm infants. Design Prospective population-based cohort. Population Singletons infants without congenital malformations born from 27 to 32 completed weeks of gestation enrolled in France in 1997 in the EPIPAGE cohort. Methods The neonatal and long-term follow-up outcomes of preterm infants were compared between those in breech presentation and those in vertex presentation. The relation of fetal presentation with neonatal mortality and neurodevelopmental outcomes was assessed using multiple logistic regression models. Results Among the 1518 infants alive at onset of labor included in this analysis (351 in breech presentation), 1392 were alive at discharge. Among those eligible to follow up and alive at 8 years, follow-up data were available for 1188 children. Neonatal mortality was significantly higher among breech than vertex infants (10.8% vs. 7.5%, P = 0.05). However the differences were not significant after controlling for potential confounders. Neonatal morbidity did not differ significantly according to fetal presentation. Severe cerebral palsy was less frequent in the group born in breech compared to vertex presentation but there was no difference after adjustment. There was no difference according to fetal presentation in cognitive deficiencies/learning disabilities or overall deficiencies. Conclusion Our data suggest that breech presentation is not an independent risk factor for neonatal mortality or long-term neurologic deficiencies among very preterm infants.
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Affiliation(s)
- Elie Azria
- INSERM, U-1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, DHU Risk in Pregnancy, Paris, France
- Department of Obstetrics, Groupe Hospitalier Paris Saint Joseph, Paris Descartes University, Paris, France
- * E-mail:
| | - Gilles Kayem
- INSERM, U-1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, DHU Risk in Pregnancy, Paris, France
- Department of Obstetrics, Groupe Hospitalier Paris Saint Joseph, Paris Descartes University, Paris, France
- Department of Obstetrics and Gynecology, Hôpital Trousseau, Assistance Publique des Hôpitaux de Paris, University Pierre et Marie Curie, Paris, France
| | - Bruno Langer
- Department of Gynecology Obstetrics, Strasbourg University Hospitals, Hôpital de Hautepierre, Strasbourg, France
| | - Laetitia Marchand-Martin
- INSERM, U-1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, DHU Risk in Pregnancy, Paris, France
| | - Stephane Marret
- Department of Neonatal Medicine, Rouen University Hospital, Rouen, France
- INSERM, AVENIR Research Group & Department of Neonatal Medicine and Intensive Care and Regional Center for Diagnosis and Research on Developmental Language and Behavioural Disorders, Rouen Institute for Biomedical Research, Rouen, France
| | - Jeanne Fresson
- INSERM, U-1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, DHU Risk in Pregnancy, Paris, France
- Department of Obstetrics, Groupe Hospitalier Paris Saint Joseph, Paris Descartes University, Paris, France
- Department of Obstetrics and Gynecology, Hôpital Trousseau, Assistance Publique des Hôpitaux de Paris, University Pierre et Marie Curie, Paris, France
- Department of Gynecology Obstetrics, Strasbourg University Hospitals, Hôpital de Hautepierre, Strasbourg, France
- Department of Neonatal Medicine, Rouen University Hospital, Rouen, France
- INSERM, AVENIR Research Group & Department of Neonatal Medicine and Intensive Care and Regional Center for Diagnosis and Research on Developmental Language and Behavioural Disorders, Rouen Institute for Biomedical Research, Rouen, France
- Medical Information Department, Regional Maternity University Hospital, Nancy, France
| | - Véronique Pierrat
- INSERM, U-1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, DHU Risk in Pregnancy, Paris, France
- Department of Obstetrics, Groupe Hospitalier Paris Saint Joseph, Paris Descartes University, Paris, France
- Department of Obstetrics and Gynecology, Hôpital Trousseau, Assistance Publique des Hôpitaux de Paris, University Pierre et Marie Curie, Paris, France
- Department of Gynecology Obstetrics, Strasbourg University Hospitals, Hôpital de Hautepierre, Strasbourg, France
- Department of Neonatal Medicine, Rouen University Hospital, Rouen, France
- INSERM, AVENIR Research Group & Department of Neonatal Medicine and Intensive Care and Regional Center for Diagnosis and Research on Developmental Language and Behavioural Disorders, Rouen Institute for Biomedical Research, Rouen, France
- Medical Information Department, Regional Maternity University Hospital, Nancy, France
- Department of Neonatal Medicine, Hôpital Jeanne de Flandre, Lille, France
| | - Catherine Arnaud
- INSERM, UMR 1027 Inserm, Toulouse III University, F-31000, Toulouse, France
- Clinical epidemiology unit, University Hospital, F-31000, Toulouse, France
| | - François Goffinet
- INSERM, U-1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, DHU Risk in Pregnancy, Paris, France
- Department of Obstetrics, Groupe Hospitalier Paris Saint Joseph, Paris Descartes University, Paris, France
- Department of Obstetrics and Gynecology, Hôpital Trousseau, Assistance Publique des Hôpitaux de Paris, University Pierre et Marie Curie, Paris, France
- Department of Gynecology Obstetrics, Strasbourg University Hospitals, Hôpital de Hautepierre, Strasbourg, France
- Department of Neonatal Medicine, Rouen University Hospital, Rouen, France
- INSERM, AVENIR Research Group & Department of Neonatal Medicine and Intensive Care and Regional Center for Diagnosis and Research on Developmental Language and Behavioural Disorders, Rouen Institute for Biomedical Research, Rouen, France
- Medical Information Department, Regional Maternity University Hospital, Nancy, France
- Department of Neonatal Medicine, Hôpital Jeanne de Flandre, Lille, France
- INSERM, UMR 1027 Inserm, Toulouse III University, F-31000, Toulouse, France
- Clinical epidemiology unit, University Hospital, F-31000, Toulouse, France
- Department of Obstetrics and Gynecology, Port-Royal Maternity, Groupe Hospitalier Cochin-Broca-Hôtel Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Monique Kaminski
- INSERM, U-1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, DHU Risk in Pregnancy, Paris, France
| | - Pierre-Yves Ancel
- INSERM, U-1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, DHU Risk in Pregnancy, Paris, France
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Perinatal practice in extreme premature delivery: variation in Dutch physicians' preferences despite guideline. Eur J Pediatr 2016; 175:1039-46. [PMID: 27251669 PMCID: PMC4930484 DOI: 10.1007/s00431-016-2741-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/19/2016] [Accepted: 05/25/2016] [Indexed: 11/04/2022]
Abstract
UNLABELLED Decisions at the limits of viability about initiating care are challenging. We aimed to investigate physicians' preferences on treatment decisions, against the background of the 2010 Dutch guideline offering active care from 24(+0/7) weeks of gestational age (GA). Obstetricians' and neonatologists' opinions were compared. An online survey was conducted amongst all perinatal professionals (n = 205) of the 10 Dutch level III perinatal care centers. Response rate was 60 % (n = 122). Comfort care was mostly recommended below 24(+0/7) weeks and intensive care over 26(+0/7) weeks. The professional views varied most at 24 and 25 weeks, with intensive care recommended but comfort care at parental request optional being the median. There was a wide range in perceived lowest limits of GA for interventions as a caesarian section and a neonatologist present at birth. Obstetricians and neonatologists disagreed on the lowest limit providing chest compressions and administering epinephrine for resuscitation. The main factors restricting active treatment were presence of congenital disorders, "small for gestational age" fetus, and incomplete course of corticosteroids. CONCLUSION There was a wide variety in individually preferred treatment decisions, especially when aspects were not covered in the Dutch guideline on perinatal practice in extreme prematurity. Furthermore, obstetricians and neonatologists did not always agree. WHAT IS KNOWN • Cross-cultural differences exists in the preferred treatment at the limits of viability • In the Netherlands since 2010, intensive care can be offered starting at 24 (+0/7) weeks gestation What is new: • There was a wide variety in preferred treatment decisions at the limits of viability especially when aspects were not covered in the Dutch national guideline on perinatal practice in extreme prematurity.
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McBride CA, Bernstein IM, Badger GJ, Horbar JD, Soll RF. The effect of maternal hypertension on mortality in infants 22, 29weeks gestation. Pregnancy Hypertens 2015; 5:362-6. [PMID: 26597755 DOI: 10.1016/j.preghy.2015.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 10/06/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the effect of maternal hypertension on mortality risk prior to discharge, in infants 22+0 to 29+6weeks gestational age. STUDY DESIGN We evaluated 88,275 North American infants whose births were recorded in Vermont Oxford Network centers between 2008 and 2011 Infants born between 22+0 and 29+6weeks gestational age were evaluated in 2-week gestational age cohorts and followed until death or discharge. Logistic regression was used to adjust for birth weight, antenatal steroid exposure, infant sex, maternal race, inborn/outborn, prenatal care and birth year. RESULTS 21,896 infants were born to hypertensive mothers; 13% died prior to Neonatal Intensive Care Unit discharge compared to 20% of the 66,379 infants born to mothers without hypertension. After adjustment, infants had significantly lower mortality compared to preterm infants not born to hypertensive mothers, at all gestational ages examined (22/23: odds ratio (OR)=0.65 (95% Confidence Interval (CI): 0.55, 0.77; 24/25); OR=0.77 (95% CI: 0.71, 0.84); 26/27: OR=0.66 (95% CI: 0.59, 0.74); 28/29: OR=0.58 (95% CI: 0.51, 0.67). Additionally, births associated with maternal hypertension increase dramatically by gestational age, resulting in a larger proportion of births associated with maternal hypertension at later gestational ages. CONCLUSIONS Preterm birth due to any cause carries significant risk of mortality, especially at the earliest of viable gestational ages. Maternal hypertension independently influences mortality, with lower odds of mortality seen in infants born to hypertensive mothers, after adjustment, and should be taken into consideration as an element in counseling parents.
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Affiliation(s)
- Carole A McBride
- University of Vermont, Department of Obstetrics, Gynecology and Reproductive Sciences, Burlington, VT 05405, United States.
| | - Ira M Bernstein
- University of Vermont, Department of Obstetrics, Gynecology and Reproductive Sciences, Burlington, VT 05405, United States; Vermont Oxford Network, Burlington, VT 05401, United States
| | - Gary J Badger
- University of Vermont, Department of Medical Biostatistics, Burlington, VT 05405, United States
| | - Jeffrey D Horbar
- University of Vermont, Department of Pediatrics, Burlington, VT 05405, United States; Vermont Oxford Network, Burlington, VT 05401, United States
| | - Roger F Soll
- University of Vermont, Department of Pediatrics, Burlington, VT 05405, United States; Vermont Oxford Network, Burlington, VT 05401, United States
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Källén K, Serenius F, Westgren M, Maršál K. Impact of obstetric factors on outcome of extremely preterm births in Sweden: prospective population-based observational study (EXPRESS). Acta Obstet Gynecol Scand 2015; 94:1203-14. [PMID: 26249263 DOI: 10.1111/aogs.12726] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/31/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION A population-based observational study investigated the contribution of obstetric factors to the survival and postnatal development of extremely preterm infants. MATERIAL AND METHODS Mortality up to 1 year and neurodevelopment at 2.5 years (Bayley-III test, cerebral palsy, vision, hearing) were evaluated in infants born before 27 weeks of gestation in Sweden 2004-2007 (n = 1011), using logistic regression analyses of risk factors. RESULTS Of 844 fetuses alive at admission, 8.4% died in utero before labor, 7.8% died intrapartum. Of 707 live-born infants, 15% died within 24 h, 70% survived ≥365 days, 64% were assessed at 2.5 years. The risk of death within 24 h after birth decreased with gestational age [odds ratio (OR) 0.3; 95% CI 0.2-0.4], antenatal corticosteroids (OR 0.3; 95% CI 0.1-0.6), and cesarean section (OR 0.4; 95% CI 0.2-0.9); it increased with multiple birth (OR 3.0; 95% CI 1.5-6.0), vaginal breech delivery (OR 2.3; 95% CI 1.0-5.1), 5-min Apgar score <4 (OR 50.4; 95% CI 28.2-90.2), and birth at a level II hospital (OR 2.6; 95% CI 1.2-5.3). The risk of death between 1 and 365 days remained significantly decreased for gestational age and corticosteroids. The risk of mental developmental delay at 2.5 years decreased with gestational age, birthweight and fetal growth; it increased with vaginal breech delivery (OR 2.0; 95% CI 1.2-7.4), male gender, low Apgar score and high Clinical Risk Index for Babies score. CONCLUSION Several obstetric factors, including abdominal delivery, influenced the risk of death within the first day of life, but not later. Antenatal corticosteroids and gestational age decreased the mortality up to 1 year. Mental developmental delay was related to vaginal breech delivery.
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Affiliation(s)
- Karin Källén
- Centre for Reproductive Epidemiology, Lund University, Lund, Sweden
| | - Fredrik Serenius
- Women's and Children's Health, Section for Pediatrics, Uppsala University, Uppsala, Sweden.,Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Magnus Westgren
- Department of Obstetrics and Gynecology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Karel Maršál
- Department of Obstetrics and Gynecology, Clinical Sciences Lund, Lund University, Lund, Sweden
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Goh A, Browning Carmo K, Morris J, Berry A, Wall M, Abdel-Latif M. Outcomes of high-risk obstetric transfers in New South Wales and the Australian Capital Territory: The High-Risk Obstetric Transfer Study. Aust N Z J Obstet Gynaecol 2015; 55:434-9. [PMID: 26174544 DOI: 10.1111/ajo.12375] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 02/13/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND In New South Wales and the Australian Capital Territory, in utero transfers to manage maternal or neonatal risks are highly challenging owing to geography and centralisation of tertiary perinatal care. AIMS The study aims to document the outcomes of high-risk obstetric transfers. MATERIALS AND METHODS A prospective observational study was conducted from 2010 to 2011 documenting urgent requests for obstetric transfers to tertiary centres across NSW/ACT for pregnancies 20 weeks' gestation or greater. Outcomes of transfers were allocated apriori to 'delivered at the receiving hospital', 'failed/delayed transfer' or 'discharged/transferred undelivered'. Our hypothesis is that each outcome has a specific group of associated clinical factors. RESULTS Of the 249 transfer requests included in the study, 40% delivered at the receiving hospital, 7% were failed/delayed transfers, and 45% were discharged/transferred undelivered. Cases delivering at the receiving hospital were significantly associated with older mothers, twin pregnancies, pregnancy induced hypertension (PIH) or premature rupture of membranes (PROM) with/without threatened preterm labour (TPL) as the indications for transfer and having three indications for transfer. Cases that were discharged/transferred undelivered were significantly associated with singleton pregnancies, TPL and/or antepartum haemorrhage (APH) as the indication for transfer and having one indication for transfer. There were no significantly associated factors for failed/delayed transfers. CONCLUSIONS The study confirms the hypothesis that particular transfer outcomes are associated with different factors. The findings also show that less than half of urgent obstetric transfers result in delivery at the receiving hospital, suggesting that there exists significant opportunities for further research into predicting preterm delivery, thereby improving the care of women with high-risk pregnancies.
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Affiliation(s)
- Amy Goh
- Department of Obstetrics and Gynaecology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Kathryn Browning Carmo
- Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Newborn and Paediatric Emergency Transport Service, Westmead, New South Wales, Australia
| | - Jonathan Morris
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St. Leonard, New South Wales, Australia.,University of Sydney Medical School, Sydney, New South Wales, Australia
| | - Andrew Berry
- Newborn and Paediatric Emergency Transport Service, Westmead, New South Wales, Australia
| | - Margaret Wall
- Newborn and Paediatric Emergency Transport Service, Westmead, New South Wales, Australia
| | - Mohamed Abdel-Latif
- Neonatology Unit, Canberra Hospital, Garran, Australian Capital Territory, Australia.,The Clinical School, Australian National University, Canberra, Australian Capital Territory, Australia
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Serenius F, Blennow M, Maršál K, Sjörs G, Källen K. Intensity of perinatal care for extremely preterm infants: outcomes at 2.5 years. Pediatrics 2015; 135:e1163-72. [PMID: 25896833 DOI: 10.1542/peds.2014-2988] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine the association between intensity of perinatal care and outcome at 2.5 years' corrected age (CA) in extremely preterm (EPT) infants (<27 weeks) born in Sweden during 2004-2007. METHODS A national prospective study in 844 fetuses who were alive at the mother's admission for delivery: 707 were live born, 137 were stillborn. Infants were assigned a perinatal activity score on the basis of the intensity of care (rates of key perinatal interventions) in the infant's region of birth. Scores were calculated separately for each gestational week (gestational age [GA]-specific scores) and for the aggregated cohort (aggregated activity scores). Primary outcomes were 1-year mortality and death or neurodevelopmental disability (NDI) at 2.5 years' CA in fetuses who were alive at the mother's admission. RESULTS Each 5-point increment in GA-specific activity score reduced the stillbirth risk (adjusted odds ratio [aOR]: 0.90; 95% confidence interval [CI]: 0.83-0.97) and the 1-year mortality risk (aOR: 0.84; 95% CI: 0.78-0.91) in the primary population and the 1-year mortality risk in live-born infants (aOR: 0.86; 95% CI: 0.79-0.93). In health care regions with higher aggregated activity scores, the risk of death or NDI at 2.5 years' CA was reduced in the primary population (aOR: 0.69; 95% CI: 0.50-0.96) and in live-born infants (aOR: 0.68; 95% CI: 0.48-0.95). Risk reductions were confined to the 22- to 24-week group. There was no difference in NDI risk between survivors at 2.5 years' CA. CONCLUSIONS Proactive perinatal care decreased mortality without increasing the risk of NDI at 2.5 years' CA in EPT infants. A proactive approach based on optimistic expectations of a favorable outcome is justified.
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Affiliation(s)
- Fredrik Serenius
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Department of Pediatrics, Institute of Clinical Sciences, Umeå University, Umeå, Sweden;
| | - Mats Blennow
- Department of Pediatrics, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Karel Maršál
- Department of Obstetrics and Gynecology, Lund University, Lund, Sweden
| | - Gunnar Sjörs
- Department of Pediatrics, Uppsala University Hospital, Uppsala, Sweden; and
| | - Karin Källen
- Centre for Reproductive Epidemiology, Lund University, Lund, Sweden
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Goya M, Cespedes MC, Camba F, Capote S, Felipe A, Reixachs A, Medina D, Gorraiz V, Pin S, Halachian C, Gracia A, Perapoch J, Cabero L, Carreras E. Antenatal corticosteroids and perinatal outcomes in infants born at 23-25 weeks of gestation. J Matern Fetal Neonatal Med 2014; 28:2084-9. [PMID: 25367557 DOI: 10.3109/14767058.2014.978280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To evaluate the perinatal results of infants born between 23 and 25.6 weeks of gestation. METHODS Medical charts of all women giving birth prematurely (23-25.6 w) from January 2005 to December 2011 were retrospectively reviewed. Cases of malformed infants or deliveries elsewhere were excluded. RESULTS 198 infants were included. Chorioamnionitis occurred in 86 (43.4%) of the whole group: 26 (86.7%) in the 23-week; 35 (53.8%) in the 24-week and 25 (24.3%) in the 25-week groups. Foetal maturation with antenatal corticosteroids was complete in 119 cases (60.1%): 4 (13.3%) in the 23-week; 35 (53.8%) in the 24-week and 80 (77.7%) in the 25-week groups. Foetal death at birth occurred in 22 cases (11%) and 61 newborns (30.8%) died in the neonatal period. Of the 106 survivors with 2 years complete follow-up, 45 infants (42.4%) did not present sequelae; 16 infants (15.1%) had severe sequelae. A 66.6% (4) of infants born at 23 weeks of gestation did not present sequelae compared with a 32.3% (11) at 24 weeks and 45.4% (30) at 25 weeks. CONCLUSIONS The chorioamnionitis rate was higher when gestational age was lower. The foetal maturation rate was higher when gestational age was higher. A low severe sequelae rate was observed in the whole series, particularly in the 23-week group where the rate was lower than expected; however, these results could have been influenced by the small size of the 23-week group.
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Affiliation(s)
- M Goya
- a Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Unit , Hospital Vall d'Hebron , Barcelona , Spain and
| | - M C Cespedes
- b Department of Pediatrics, Neonatal Intensive Care Unit , Hospital Vall d'Hebron , Barcelona , Spain
| | - F Camba
- b Department of Pediatrics, Neonatal Intensive Care Unit , Hospital Vall d'Hebron , Barcelona , Spain
| | - S Capote
- a Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Unit , Hospital Vall d'Hebron , Barcelona , Spain and
| | - A Felipe
- b Department of Pediatrics, Neonatal Intensive Care Unit , Hospital Vall d'Hebron , Barcelona , Spain
| | - A Reixachs
- a Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Unit , Hospital Vall d'Hebron , Barcelona , Spain and
| | - D Medina
- b Department of Pediatrics, Neonatal Intensive Care Unit , Hospital Vall d'Hebron , Barcelona , Spain
| | - V Gorraiz
- a Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Unit , Hospital Vall d'Hebron , Barcelona , Spain and
| | - S Pin
- b Department of Pediatrics, Neonatal Intensive Care Unit , Hospital Vall d'Hebron , Barcelona , Spain
| | - C Halachian
- a Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Unit , Hospital Vall d'Hebron , Barcelona , Spain and
| | - A Gracia
- a Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Unit , Hospital Vall d'Hebron , Barcelona , Spain and
| | - J Perapoch
- b Department of Pediatrics, Neonatal Intensive Care Unit , Hospital Vall d'Hebron , Barcelona , Spain
| | - L Cabero
- a Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Unit , Hospital Vall d'Hebron , Barcelona , Spain and
| | - E Carreras
- a Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Unit , Hospital Vall d'Hebron , Barcelona , Spain and
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Delnord M, Blondel B, Drewniak N, Klungsøyr K, Bolumar F, Mohangoo A, Gissler M, Szamotulska K, Lack N, Nijhuis J, Velebil P, Sakkeus L, Chalmers J, Zeitlin J. Varying gestational age patterns in cesarean delivery: an international comparison. BMC Pregnancy Childbirth 2014; 14:321. [PMID: 25217979 PMCID: PMC4177602 DOI: 10.1186/1471-2393-14-321] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 09/04/2014] [Indexed: 11/10/2022] Open
Abstract
Background While international variations in overall cesarean delivery rates are well documented, less information is available for clinical sub-groups. Cesarean data presented by subgroups can be used to evaluate uptake of cesarean reduction policies or to monitor delivery practices for high and low risk pregnancies based on new scientific evidence. We studied differences and patterns in cesarean delivery rates by multiplicity and gestational age in Europe and the United States. Methods This study used routine aggregate data from 17 European countries and the United States on the number of singleton and multiple live births with cesarean versus vaginal delivery by week of gestation in 2008. Overall and gestation-specific cesarean delivery rates were analyzed. We computed rate differences to compare mode of delivery (cesarean vs vaginal birth) between selected gestational age groups and studied associations between rates in these subgroups namely: very preterm (26–31 weeks GA), moderate preterm (32–36 weeks GA), near term (37–38 weeks GA), term (39–41 weeks GA) and post-term (42+ weeks GA) births, using Spearman’s rank tests. Results High variations in cesarean rates for singletons and multiples were observed everywhere. Rates for singletons varied from 15% in The Netherlands and Slovenia, to over 30% in the US and Germany. In singletons, rates were highest for very preterm births and declined to a nadir at 40 weeks of gestation, ranging from 8.0% in Sweden and Norway, to 22.5% in the US. These patterns differed across countries; the average rate difference between very preterm and term births was 43 percentage points, but ranged from 14% to 61%. High variations in rate differences were also observed for near term versus term births. For multiples, rates declined by gestational age in some countries, whereas in others rates were similar across all weeks of gestation. Countries’ overall cesarean rates were highly correlated with gestation-specific subgroup rates, except for very preterm births. Conclusions Gestational age patterns in cesarean delivery were heterogeneous across countries; these differences highlight areas where consensus on best practices is lacking and could be used in developing strategies to reduce cesareans.
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Affiliation(s)
- Marie Delnord
- INSERM UMR1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité (CRESS), DHU Risks in pregnancy, Paris Descartes University, Port Royal Maternity Unit, 53 Avenue de l'Observatoire, Paris, 75014, France.
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Raju TNK, Mercer BM, Burchfield DJ, Joseph GF. Periviable birth: executive summary of a Joint Workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists. J Perinatol 2014; 34:333-42. [PMID: 24722647 DOI: 10.1038/jp.2014.70] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 02/21/2014] [Indexed: 11/09/2022]
Abstract
This is an executive summary of a workshop on the management and counseling issues of women anticipated to deliver at a periviable gestation (broadly defined as 20 0/7 through 25 6/7 weeks of gestation), and the treatment options for the newborn. Upon review of the available literature, the workshop panel noted that the rates of neonatal survival and neurodevelopmental disabilities among the survivors vary greatly across the periviable gestations and are significantly influenced by the obstetric and neonatal management practices (for example, antenatal steroid, tocolytic agents and antibiotic administration; cesarean birth; and local protocols for perinatal care, neonatal resuscitation and intensive care support). These are, in turn, influenced by the variations in local and regional definitions of limits of viability. Because of the complexities in making difficult management decisions, obstetric and neonatal teams should confer prior to meeting with the family, when feasible. Family counseling should be coordinated with the goal of creating mutual trust, respect and understanding, and should incorporate evidence-based counseling methods. Since clinical circumstances can change rapidly with increasing gestational age, counseling should include discussion of the benefits and risks of various maternal and neonatal interventions at the time of counseling. There should be a plan for follow-up counseling as clinical circumstances evolve. The panel proposed a research agenda and recommended developing educational curricula on the care and counseling of families facing the birth of a periviable infant.
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Affiliation(s)
- T N K Raju
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - B M Mercer
- The Society for Maternal-Fetal Medicine and Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, USA
| | - D J Burchfield
- The American Academy of Pediatrics and University of Florida, Gainesville, FL, USA
| | - G F Joseph
- The American College of Obstetricians and Gynecologists, Washington, DC, USA
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Periviable birth: executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists. Am J Obstet Gynecol 2014; 210:406-17. [PMID: 24725732 DOI: 10.1016/j.ajog.2014.02.027] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 02/25/2014] [Indexed: 01/01/2023]
Abstract
This is an executive summary of a workshop on the management and counseling issues of women anticipated to deliver at a periviable gestation (broadly defined as 20 0/7 through 25 6/7 weeks of gestation) and the treatment options for the newborn infant. Upon review of the available literature, the workshop panel noted that the rates of neonatal survival and neurodevelopmental disabilities among the survivors vary greatly across the periviable gestations and are significantly influenced by the obstetric and neonatal management practices (eg, antenatal steroid, tocolytic agents, and antibiotic administration; cesarean birth; and local protocols for perinatal care, neonatal resuscitation, and intensive care support). These are, in turn, influenced by the variations in local and regional definitions of limits of viability. Because of the complexities in making difficult management decisions, obstetric and neonatal teams should confer prior to meeting with the family, when feasible. Family counseling should be coordinated with the goal of creating mutual trust, respect, and understanding and should incorporate evidence-based counseling methods. Since clinical circumstances can change rapidly with increasing gestational age, counseling should include discussion of the benefits and risks of various maternal and neonatal interventions at the time of counseling. There should be a plan for follow-up counseling as clinical circumstances evolve. The panel proposed a research agenda and recommended developing educational curricula on the care and counseling of families facing the birth of a periviable infant.
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Suciu LM, Puscasiu L, Szabo B, Cucerea M, Ognean ML, Oprea I, Bell EF. Mortality and morbidity of very preterm infants in Romania: how are we doing? Pediatr Int 2014; 56:200-6. [PMID: 24015920 DOI: 10.1111/ped.12219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 07/31/2013] [Accepted: 08/26/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Birth before 28 weeks of gestation is associated with high mortality and morbidity. The purpose of this study was to examine characteristics associated with in-hospital mortality and morbidity among extremely low-birthweight neonates admitted to three tertiary care centers in Romania. METHODS The study was conducted in three Romanian hospitals with level-III neonatal intensive care units. We studied singleton live births at the established Romanian limit of viability (i.e., 25-28 weeks' gestational age) born between January 2007 and December 2010 (n = 227). Infants born in non-level-III facilities transferred to these three centers were included in our study (n = 39). Descriptive and multivariate statistical analyses were used to describe the population and examine outcomes and risk factors. RESULTS During the study period, 62 neonates (27.3%) were delivered at 25 weeks, 56 (24.7%) were delivered at 26 weeks, 56 (24.7%) at 27 weeks, and 53 (23.3%) at 28 weeks. Overall in-hospital mortality was 65% (from 85% at 25 weeks to 35% at 28 weeks). The rates for major morbidities were necrotizing enterocolitis 8.8%, bronchopulmonary dysplasia 12.5%, and retinopathy of prematurity (stage higher than 2) 26.2%. CONCLUSIONS During 2007-2010, in-hospital survival of infants admitted to three neonatal intensive care units in Romania was 35% and ranged from 14% at 25 weeks to 64% at 28 weeks.
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Affiliation(s)
- Laura Mihaela Suciu
- Department of Pediatrics, University of Medicine and Pharmacy Tirgu Mures, Tirgu Mures
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36
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Serenius F, Sjörs G, Blennow M, Fellman V, Holmström G, Maršál K, Lindberg E, Olhager E, Stigson L, Westgren M, Källen K. EXPRESS study shows significant regional differences in 1-year outcome of extremely preterm infants in Sweden. Acta Paediatr 2014; 103:27-37. [PMID: 24053771 PMCID: PMC4034585 DOI: 10.1111/apa.12421] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 08/12/2013] [Accepted: 09/11/2013] [Indexed: 11/29/2022]
Abstract
Aim The aim of this study was to investigate differences in mortality up to 1 year of age in extremely preterm infants (before 27 weeks) born in seven Swedish healthcare regions. Methods National prospective observational study of consecutively born, extremely preterm infants in Sweden 2004–2007. Mortality was compared between regions. Crude and adjusted odds ratios and 95% CI were calculated. Results Among 844 foetuses alive at mother's admission for delivery, regional differences were identified in perinatal mortality for the total group (22–26 weeks) and in the stillbirth and perinatal and 365-day mortality rates for the subgroup born at 22–24 weeks. Among 707 infants born alive, regional differences were found both in mortality before 12 h and in the 365-day mortality rate for the subgroup (22–24 weeks) and for the total group (22–26 weeks). The mortality rates were consistently lower in two healthcare regions. There were no differences in the 365-day mortality rate for infants alive at 12 h or for infants born at 25 weeks. Neonatal morbidity rates among survivors were not higher in regions with better survival rates. Perinatal practices varied between regions. Conclusion Mortality rates in extremely preterm infants varied considerably between Swedish healthcare regions in the first year after birth, particularly between the most immature infants.
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Affiliation(s)
- Fredrik Serenius
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
- Department of Pediatrics Institute of Clinical Sciences Umeå University Umeå Sweden
| | - Gunnar Sjörs
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
| | - Mats Blennow
- Department of Pediatrics Karolinska University Hospital Huddinge Stockholm Sweden
| | | | - Gerd Holmström
- Department Ophthalmology Uppsala University Uppsala Sweden
| | - Karel Maršál
- Department of Obstetrics and Gynecology Lund University Lund Sweden
| | - Eva Lindberg
- Department of Pediatrics Örebro University Örebro Sweden
| | | | - Lennart Stigson
- Department of Pediatrics Sahlgrenska University Hospital Göteborg Sweden
| | - Magnus Westgren
- Department of Obstetrics and Gynecology Karolinska University Hospital Huddinge Stockholm Sweden
| | - Karin Källen
- Centre for Reproductive Epidemiology Lund University Lund Sweden
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Mohangoo AD, Blondel B, Gissler M, Velebil P, Macfarlane A, Zeitlin J. International comparisons of fetal and neonatal mortality rates in high-income countries: should exclusion thresholds be based on birth weight or gestational age? PLoS One 2013; 8:e64869. [PMID: 23700489 PMCID: PMC3658983 DOI: 10.1371/journal.pone.0064869] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 04/19/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Fetal and neonatal mortality rates are essential indicators of population health, but variations in recording of births and deaths at the limits of viability compromises international comparisons. The World Health Organization recommends comparing rates after exclusion of births with a birth weight less than 1000 grams, but many analyses of perinatal outcomes are based on gestational age. We compared the effects of using a 1000-gram birth weight or a 28-week gestational age threshold on reported rates of fetal and neonatal mortality in Europe. METHODS Aggregated data from 2004 on births and deaths tabulated by birth weight and gestational age from 29 European countries/regions participating in the Euro-Peristat project were used to compute fetal and neonatal mortality rates using cut-offs of 1000-grams and 28-weeks (2.8 million total births). We measured differences in rates between and within countries using the Wilcoxon signed rank test and 95% confidence intervals, respectively. PRINCIPAL FINDINGS For fetal mortality, rates based on gestational age were significantly higher than those based on birth weight (p<0.001), although these differences varied between countries. The use of a 1000-gram threshold included 8823 fetal deaths compared with 9535 using a 28-week threshold (difference of 712). In contrast, the choice of a cut-off made little difference for comparisons of neonatal deaths (difference of 16). Neonatal mortality rates differed minimally, by under 0.1 per 1000 in most countries (p = 0.370). Country rankings were comparable with both thresholds. CONCLUSIONS Neonatal mortality rates were not affected by the choice of a threshold. However, the use of a 1000-gram threshold underestimated the health burden of fetal deaths. This may in part reflect the exclusion of growth restricted fetuses. In high-income countries with a good measure of gestational age, using a 28-week threshold may provide additional valuable information about fetal deaths occurring in the third trimester.
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Affiliation(s)
- Ashna D Mohangoo
- Department of Child Health, TNO, Netherlands Organization for Applied Scientific Research, Leiden, The Netherlands.
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Guinsburg R, Branco de Almeida MF, Dos Santos Rodrigues Sadeck L, Marba STM, Suppo de Souza Rugolo LM, Luz JH, de Andrade Lopes JM, Martinez FE, Procianoy RS. Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists. J Perinatol 2012; 32:913-9. [PMID: 22460546 DOI: 10.1038/jp.2012.28] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To verify, in extremely preterm infants, if disagreement between obstetricians and neonatologists regarding proactive management is associated with early death. STUDY DESIGN Prospective cohort of 484 infants with 23(0/7) to 26(6/7) weeks, without malformations, born from January 2006 to December 2009 in eight Brazilian hospitals. Pro-active management was defined as indication of ≥1 dose of antenatal steroid or cesarean section (obstetrician) and resuscitation at birth according to the international guidelines (neonatologist). Main outcome was neonatal death in the first 24 h of life. RESULT Obstetricians and neonatologists disagreed in 115 (24%) patients: only neonatologists were proactive in 107 of them. Disagreement between professionals increased 2.39 times the chance of death in the first day (95% confidence interval 1.40 to 4.09), adjusted for center and maternal/neonatal clinical conditions. CONCLUSION In infants with 23 to 26 weeks of gestation, disagreement between obstetricians and neonatologists, translated as lack of antenatal steroids and/or vaginal delivery, despite resuscitation procedures, increases the odds of death in the first day.
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Affiliation(s)
- R Guinsburg
- Department of Pediatrics, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil.
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Smith PB, Ambalavanan N, Li L, Cotten CM, Laughon M, Walsh MC, Das A, Bell EF, Carlo WA, Stoll BJ, Shankaran S, Laptook AR, Higgins RD, Goldberg RN. Approach to infants born at 22 to 24 weeks' gestation: relationship to outcomes of more-mature infants. Pediatrics 2012; 129:e1508-16. [PMID: 22641761 PMCID: PMC3362905 DOI: 10.1542/peds.2011-2216] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We sought to determine if a center's approach to care of premature infants at the youngest gestational ages (22-24 weeks' gestation) is associated with clinical outcomes among infants of older gestational ages (25-27 weeks' gestation). METHODS Inborn infants of 401 to 1000 g birth weight and 22 0/7 to 27 6/7 weeks' gestation at birth from 2002 to 2008 were enrolled into a prospectively collected database at 20 centers participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Markers of an aggressive approach to care for 22- to 24-week infants included use of antenatal corticosteroids, cesarean delivery, and resuscitation. The primary outcome was death before postnatal day 120 for infants of 25 to 27 weeks' gestation. Secondary outcomes were the combined outcomes of death or a number of morbidities associated with prematurity. RESULTS Our study included 3631 infants 22 to 24 weeks' gestation and 5227 infants 25 to 27 weeks' gestation. Among the 22- to 24-week infants, use of antenatal corticosteroids ranged from 28% to 100%, cesarean delivery from 13% to 65%, and resuscitation from 30% to 100% by center. Centers with higher rates of antenatal corticosteroid use in 22- to 24-week infants had reduced rates of death, death or retinopathy of prematurity, death or late-onset sepsis, death or necrotizing enterocolitis, and death or neurodevelopmental impairment in 25- to 27-week infants. CONCLUSIONS This study suggests that physicians' willingness to provide care to extremely low gestation infants as measured by frequency of use of antenatal corticosteroids is associated with improved outcomes for more-mature infants.
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Affiliation(s)
- P. Brian Smith
- Department of Pediatrics, Duke University, Durham, North Carolina
| | | | - Lei Li
- RTI International, Research Triangle Park, North Carolina
| | | | - Matthew Laughon
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Abhik Das
- RTI International, Research Triangle Park, North Carolina
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine, and Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants’ Hospital, Brown University, Providence, Rhode Island; and
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Azria E, Anselem O, Schmitz T, Tsatsaris V, Senat MV, Goffinet F. Comparison of perinatal outcome after pre-viable preterm prelabour rupture of membranes in two centres with different rates of termination of pregnancy. BJOG 2012; 119:449-57. [DOI: 10.1111/j.1471-0528.2011.03265.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schuit E, Hukkelhoven CWPM, Manktelow BN, Papatsonis DNM, de Kleine MJK, Draper ES, Steyerberg EW, Vergouwe Y. Prognostic models for stillbirth and neonatal death in very preterm birth: a validation study. Pediatrics 2012; 129:e120-7. [PMID: 22157141 DOI: 10.1542/peds.2011-0803] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To validate externally 2 prognostic models for stillbirth and neonatal death in very preterm infants who are either known to be alive at the onset of labor or admitted for neonatal intensive care. PATIENTS AND METHODS All infants, with gestational age 22 to 32 weeks, of European ethnicity, known to be alive at the onset of labor (n = 17 582) and admitted for neonatal intensive care (n = 11 578), who were born in the Netherlands between January 1, 2000, and December 31, 2007. The main outcome measures were stillbirth or death within 28 days for infants known to be alive at the onset of labor and death before discharge from the NICU for infants admitted for intensive care. Model performance was studied with calibration plots and c statistic. RESULTS Of the infants known to be alive at the onset of labor, 16.7% (n = 2939) died during labor or within 28 days of birth, and 7.8% (n = 908) of the infants admitted for neonatal intensive care died before discharge from intensive care. The prognostic model for infants known to be alive at the onset of labor showed good calibration and excellent discrimination (c statistic 0.92). The prognostic model for infants admitted for neonatal intensive care showed good calibration and good discrimination (c statistic 0.82). CONCLUSIONS The 2 prognostic models for stillbirth and neonatal death in very preterm Dutch infants showed good performance, suggesting their use in clinical practice in the Netherlands and possibly other Western countries.
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Affiliation(s)
- Ewoud Schuit
- Centre for Medical Decision Sciences, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
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Carlo WA, McDonald SA, Fanaroff AA, Vohr BR, Stoll BJ, Ehrenkranz RA, Andrews WW, Wallace D, Das A, Bell EF, Walsh MC, Laptook AR, Shankaran S, Poindexter BB, Hale EC, Newman NS, Davis AS, Schibler K, Kennedy KA, Sánchez PJ, Van Meurs KP, Goldberg RN, Watterberg KL, Faix RG, Frantz ID, Higgins RD. Association of antenatal corticosteroids with mortality and neurodevelopmental outcomes among infants born at 22 to 25 weeks' gestation. JAMA 2011; 306:2348-58. [PMID: 22147379 PMCID: PMC3565238 DOI: 10.1001/jama.2011.1752] [Citation(s) in RCA: 244] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Current guidelines, initially published in 1995, recommend antenatal corticosteroids for mothers with preterm labor from 24 to 34 weeks' gestational age, but not before 24 weeks due to lack of data. However, many infants born before 24 weeks' gestation are provided intensive care. OBJECTIVE To determine if use of antenatal corticosteroids is associated with improvement in major outcomes for infants born at 22 and 23 weeks' gestation. DESIGN, SETTING, AND PARTICIPANTS Cohort study of data collected prospectively on inborn infants with a birth weight between 401 g and 1000 g (N = 10,541) born at 22 to 25 weeks' gestation between January 1, 1993, and December 31, 2009, at 23 academic perinatal centers in the United States. Certified examiners unaware of exposure to antenatal corticosteroids performed follow-up examinations on 4924 (86.5%) of the infants born between 1993 and 2008 who survived to 18 to 22 months. Logistic regression models generated adjusted odds ratios (AORs), controlling for maternal and neonatal variables. MAIN OUTCOME MEASURES Mortality and neurodevelopmental impairment at 18 to 22 months' corrected age. RESULTS Death or neurodevelopmental impairment at 18 to 22 months was significantly lower for infants who had been exposed to antenatal corticosteroids and were born at 23 weeks' gestation (83.4% with exposure to antenatal corticosteroids vs 90.5% without exposure; AOR, 0.58 [95% CI, 0.42-0.80]), at 24 weeks' gestation (68.4% with exposure to antenatal corticosteroids vs 80.3% without exposure; AOR, 0.62 [95% CI, 0.49-0.78]), and at 25 weeks' gestation (52.7% with exposure to antenatal corticosteroids vs 67.9% without exposure; AOR, 0.61 [95% CI, 0.50-0.74]) but not in those infants born at 22 weeks' gestation (90.2% with exposure to antenatal corticosteroids vs 93.1% without exposure; AOR, 0.80 [95% CI, 0.29-2.21]). If the mothers had received antenatal corticosteroids, the following events occurred significantly less in infants born at 23, 24, and 25 weeks' gestation: death by 18 to 22 months; hospital death; death, intraventricular hemorrhage, or periventricular leukomalacia; and death or necrotizing enterocolitis. For infants born at 22 weeks' gestation, the only outcome that occurred significantly less was death or necrotizing enterocolitis (73.5% with exposure to antenatal corticosteroids vs 84.5% without exposure; AOR, 0.54 [95% CI, 0.30-0.97]). CONCLUSION Among infants born at 23 to 25 weeks' gestation, antenatal exposure to corticosteroids compared with nonexposure was associated with a lower rate of death or neurodevelopmental impairment at 18 to 22 months.
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Affiliation(s)
- Waldemar A Carlo
- Department of Pediatrics, University of Alabama, 9380 Women and Infants Center, 1700 Sixth Ave S, Birmingham, AL 35249, USA.
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Mohangoo AD, Buitendijk SE, Szamotulska K, Chalmers J, Irgens LM, Bolumar F, Nijhuis JG, Zeitlin J. Gestational age patterns of fetal and neonatal mortality in Europe: results from the Euro-Peristat project. PLoS One 2011; 6:e24727. [PMID: 22110575 PMCID: PMC3217927 DOI: 10.1371/journal.pone.0024727] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 08/19/2011] [Indexed: 01/12/2023] Open
Abstract
Background The first European Perinatal Health Report showed wide variability between European countries in fetal (2.6–9.1‰) and neonatal (1.6–5.7‰) mortality rates in 2004. We investigated gestational age patterns of fetal and neonatal mortality to improve our understanding of the differences between countries with low and high mortality. Methodology/Principal Findings Data on 29 countries/regions participating in the Euro-Peristat project were analyzed. Most European countries had no limits for the registration of live births, but substantial variations in limits for registration of stillbirths before 28 weeks of gestation existed. Country rankings changed markedly after excluding deaths most likely to be affected by registration differences (22–23 weeks for neonatal mortality and 22–27 weeks for fetal mortality). Countries with high fetal mortality ≥28 weeks had on average higher proportions of fetal deaths at and near term (≥37 weeks), while proportions of fetal deaths at earlier gestational ages (28–31 and 32–36 weeks) were higher in low fetal mortality countries. Countries with high neonatal mortality rates ≥24 weeks, all new member states of the European Union, had high gestational age-specific neonatal mortality rates for all gestational-age subgroups; they also had high fetal mortality, as well as high early and late neonatal mortality. In contrast, other countries with similar levels of neonatal mortality had varying levels of fetal mortality, and among these countries early and late neonatal mortality were negatively correlated. Conclusions For valid European comparisons, all countries should register births and deaths from at least 22 weeks of gestation and should be able to distinguish late terminations of pregnancy from stillbirths. After excluding deaths most likely to be influenced by existing registration differences, important variations in both levels and patterns of fetal and neonatal mortality rates were found. These disparities raise questions for future research about the effectiveness of medical policies and care in European countries.
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Affiliation(s)
- Ashna D Mohangoo
- Department Child Health, TNO Netherlands Organization for Applied Scientific Research, Leiden, The Netherlands.
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Extremely Preterm Infant Mortality Rates and Cesarean Deliveries in the United States. Obstet Gynecol 2011; 118:43-48. [DOI: 10.1097/aog.0b013e318221001c] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mori R, Kusuda S, Fujimura M. Antenatal corticosteroids promote survival of extremely preterm infants born at 22 to 23 weeks of gestation. J Pediatr 2011; 159:110-114.e1. [PMID: 21334006 DOI: 10.1016/j.jpeds.2010.12.039] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Revised: 11/17/2010] [Accepted: 12/22/2010] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of antenatal corticosteroid (ACS) to improve neonatal outcomes for infants born at <24 weeks of gestation. STUDY DESIGN We performed a retrospective analysis of 11,607 infants born at 22 to 33 weeks of gestation between 2003 and 2007 from the Neonatal Research Network of Japan. We evaluated the gestational age effects of ACS administered to mothers with threatened preterm birth on several factors related to neonatal morbidity and mortality. RESULTS By logistic regression analysis, ACS exposure decreased respiratory distress syndrome and severe intraventricular hemorrhage in infants born between 24 and 29 weeks of gestation. Cox regression analysis revealed that ACS exposure was associated with a significant decrease in mortality of preterm infants born at 22 or 23 weeks of gestation (adjusted hazard ratio, 0.72; 95% CI, 0.53 to 0.97; P=.03). This effect was also observed at 24 to 25 and 26 to 27 weeks of gestation and in the overall study population. CONCLUSIONS ACS exposure improved survival of extremely preterm infants. ACS treatment should be considered for threatened preterm birth at 22 to 23 weeks of gestation.
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Affiliation(s)
- Rintaro Mori
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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Variability in caesarean section rates for very preterm births at 28-31 weeks of gestation in 10 European regions: results of the MOSAIC project. Eur J Obstet Gynecol Reprod Biol 2010; 149:147-52. [PMID: 20083337 DOI: 10.1016/j.ejogrb.2009.12.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Revised: 11/06/2009] [Accepted: 12/21/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Given the continuing debate about the benefits of caesarean section for very preterm infants, we sought to describe caesarean section rates for infants between 28 and 31 weeks of gestation in European regions and their association with regional mortality and short-term morbidity. STUDY DESIGN Singletons and twins without lethal congenital anomalies alive at onset of labour from 28 to 31 weeks of gestation from the 2003 MOSAIC cohort of very preterm births in 10 European regions were analysed (N=3,310). Determinants included maternal and fetal characteristics as well as regional caesarean section rates for all births. We explored correlations between caesarean section rates and mortality and morbidity on the regional level. RESULTS 95% of infants from pregnancies complicated by hypertension or severe growth restriction detected antenatally were delivered by caesarean section (regional range: 90-100%) versus 55.4% (range: 29-84%) for other pregnancies. Regional caesarean section rates for births at all gestations ranged from 14% to 38% and were correlated with very preterm caesarean rates (p=0.011). Determinants of caesarean section differed between regions with high versus low rates: multiples were more likely to be born by caesarean section in regions with high rates. There were no regional level correlations between caesarean section rates and mortality and morbidity. CONCLUSIONS With the exception of pregnancies with hypertension and growth restriction, there was broad variation in very preterm caesarean section rates between regions after adjustment for clinical factors. Given maternal risks associated with caesarean section, more research on its optimal use for very preterm deliveries is necessary.
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Arabin B. Emile Papiernik, 1936–2009. Twin Res Hum Genet 2009. [DOI: 10.1375/twin.12.6.616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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