Autopsy in a Neonatal Intensive Care Unit: pathological and clinical agreement

OBJECTIVES

To evaluate neonatal autopsy rates at a tertiary hospital in southern Brazil ascertain the level of agreement between premortem and postmortem diagnosis.

METHODS

The authors reviewed all neonatal autopsies performed over a 10-year period and described the percentage of neonates who died and underwent autopsy. The authors tested for agreement between autopsy findings and the cause of death as defined by the neonatologist. Agreement between clinical diagnosis and autopsy findings was classified using the modified Goldman criteria. Additional findings at autopsy were grouped by organ system. Linear regression and multiple comparisons were used for statistical analyses.

RESULTS

During the study period, 382 neonates died at the Neonatal Intensive Care Unit (NICU). Consent to perform an autopsy was obtained for 73 (19.1%). The complete agreement between autopsy findings and the neonatologist's premortem diagnosis was found in 48 patients (65.8%). Additional findings were obtained at autopsy in 25 cases (34.2%). In 5 cases (6.9%), the autopsy findings contributed to subsequent genetic counseling. Seven autopsies (9.6%) revealed a diagnosis that would have changed patient management if established premortem. The autopsy rate increased by an average of 1.87% each year.

CONCLUSION

Despite a high level of agreement between clinical diagnosis and pathological findings, autopsies provided relevant data regarding the cause of death, providing additional clinical information to neonatologists and allowing genetic counseling of family members.

Primary closure of a sternal cleft in the neonatal period

Sternal cleft is a rare malformation of the midline fusion of the sternal bars; the most common form is the superior partial defect. Surgical correction with primary closure is the gold standard. It is recommended that the procedure be performed before 3 months of age because of the greater compliance and maximal flexibility of the thoracic wall.  These features ensure a safer repair with a low risk of complications and allow for a less extensive procedure that does not require the use of additional techniques. A midline incision is performed in the anterior thoracic wall, and the major pectoralis flaps are raised. The main surgical goal is to change the remaining sternum from a U to a V shape. Transfixing interrupted sutures are placed in the cartilaginous borders for midline closure. Hemodynamics and ventilation are monitored at this time. Closure is performed by layers.

Vaginal birth after cesarean section: an update on physician trends and patient perceptions

The increased number of women having a vaginal birth after a cesarean section can be attributed to changing physician trends. Women eligible for vaginal birth after cesarean section include those with previous low vertical incisions, multiple previous incisions and even unknown scars, regardless of the method of closure or previous indication. Limited data suggest that in carefully selected women a current twin gestation, breech presentation, or the presence of fetal macrosomia are not contraindications for a trial of labor, in the presence of a uterine scar. Changing trends in the management of labor may also contribute to an increase in successful trial of labor with the use of oxytocin for the induction or augmentation of labor, the administration of epidural anesthesia for pain relief, and the instillation of prostaglandin E2 gel for cervical ripening. External cephalic version and amnioinfusion may also be reasonable alternatives in appropriately selected cases. Despite the documented safety and success of vaginal birth after cesarean section, and the lack of increased morbidity of failed trial of labor, 50% of women who are eligible for vaginal birth after cesarean section will decline an attempt, even after extensive counseling and encouragement. Patient resistance, largely attributed to the fear and inconvenience of labor, is still a major deterrent to a further rise in vaginal birth after cesarean section rates.

Clinical experience with the Hewlett-Packard M-1350A fetal monitor: correlation of Doppler-detected fetal body movements with fetal heart rate parameters and perinatal outcome

OBJECTIVE

Our purpose was to correlate measures of Doppler-detected fetal movements with standard fetal heart rate parameters and perinatal outcomes.

STUDY DESIGN

This prospective, multiinstitutional trial used the Hewlett-Packard M1350A monitor to record simultaneous fetal heart rate baseline, variability, accelerations, decelerations, and number of fetal movements, and duration and percent of total time. These data were compared at 10- and 30-minute intervals during nonstress tests and were correlated with fetal heart rate baseline parameters and maternally perceived fetal movements and with outcomes of infants delivered within 7 days of the last test.

RESULTS

At six centers 1704 actocardiograms from 884 third-trimester patients were analyzed. Doppler-detected fetal movement counts, durations, and percent of total time correlated weakly with all baseline fetal heart rate parameters (all values < 0.20). All fetal movement parameters increased significantly in successive 10-minute blocks and in periods of increased or normal fetal heart rate variability compared with those with fetal heart rate variability. The sensitivity, specificity, and predictive values of the percent of total movement time were comparable to those of standard nonstress test parameters. The risk of poor perinatal outcomes after nonreactive nonstress tests was lower in cases with fetal movements than in those without.

CONCLUSIONS

Doppler actocardiography may help to discriminate fetal states during antepartum testing. It may prevent inappropriate diagnosis of fetal compromise when the nonstress test is nonreactive or nonreassuring.

Management of isoimmunized pregnancy by use of intravascular techniques

Twenty-two patients who had 23 pregnancies complicated by isoimmunization were managed by the use of intravascular methods on an outpatient basis. Nine patients underwent 30 percutaneous fetal blood sampling procedures to determine fetal blood type or hematocrit, without complication. Thirteen patients underwent 45 intrauterine fetal transfusions via the umbilical vessels and 16 intraperitoneal fetal transfusions. The overall survival rate in this series was 85.7%. Survival among fetuses that were hydropic at initial evaluation was 83.3%. The procedure-related perinatal mortality rate for intravascular intrauterine transfusions was 2.2%. Knowledge of fetal blood type and hematocrit allowed treatment individualized to the specific needs of each patient. In particular, the ability to transfuse blood directly into the vascular system of the hydropic fetus proved to be lifesaving in those patients.