Neonatal mortality risk of large-for-gestational-age and macrosomic live births in 15 countries, including 115.6 million nationwide linked records, 2000-2020

OBJECTIVE

We aimed to compare the prevalence and neonatal mortality associated with large for gestational age (LGA) and macrosomia among 115.6 million live births in 15 countries, between 2000 and 2020.

DESIGN

Population-based, multi-country study.

SETTING

National healthcare systems.

POPULATION

Liveborn infants.

METHODS

We used individual-level data identified for the Vulnerable Newborn Measurement Collaboration. We calculated the prevalence and relative risk (RR) of neonatal mortality among live births born at term + LGA (>90th centile, and also >95th and >97th centiles when the data were available) versus term + appropriate for gestational age (AGA, 10th-90th centiles) and macrosomic (≥4000, ≥4500 and ≥5000 g, regardless of gestational age) versus 2500-3999 g. INTERGROWTH 21st served as the reference population.

MAIN OUTCOME MEASURES

Prevalence and neonatal mortality risks.

RESULTS

Large for gestational age was common (median prevalence 18.2%; interquartile range, IQR, 13.5%-22.0%), and overall was associated with a lower neonatal mortality risk compared with AGA (RR 0.83, 95% CI 0.77-0.89). Around one in ten babies were ≥4000 g (median prevalence 9.6% (IQR 6.4%-13.3%), with 1.2% (IQR 0.7%-2.0%) ≥4500 g and with 0.2% (IQR 0.1%-0.2%) ≥5000 g). Overall, macrosomia of ≥4000 g was not associated with increased neonatal mortality risk (RR 0.80, 95% CI 0.69-0.94); however, a higher risk was observed for birthweights of ≥4500 g (RR 1.52, 95% CI 1.10-2.11) and ≥5000 g (RR 4.54, 95% CI 2.58-7.99), compared with birthweights of 2500-3999 g, with the highest risk observed in the first 7 days of life.

CONCLUSIONS

In this population, birthweight of ≥4500 g was the most useful marker for early mortality risk in big babies and could be used to guide clinical management decisions.

Neonatal mortality risk for vulnerable newborn types in 15 countries using 125.5 million nationwide birth outcome records, 2000-2020

OBJECTIVE

To compare neonatal mortality associated with six novel vulnerable newborn types in 125.5 million live births across 15 countries, 2000-2020.

DESIGN

Population-based, multi-country study.

SETTING

National data systems in 15 middle- and high-income countries.

METHODS

We used individual-level data sets identified for the Vulnerable Newborn Measurement Collaboration. We examined the contribution to neonatal mortality of six newborn types combining gestational age (preterm [PT] versus term [T]) and size-for-gestational age (small [SGA], <10th centile, appropriate [AGA], 10th-90th centile or large [LGA], >90th centile) according to INTERGROWTH-21st newborn standards. Newborn babies with PT or SGA were defined as small and T + LGA was considered as large. We calculated risk ratios (RRs) and population attributable risks (PAR%) for the six newborn types.

MAIN OUTCOME MEASURES

Mortality of six newborn types.

RESULTS

Of 125.5 million live births analysed, risk ratios were highest among PT + SGA (median 67.2, interquartile range [IQR] 45.6-73.9), PT + AGA (median 34.3, IQR 23.9-37.5) and PT + LGA (median 28.3, IQR 18.4-32.3). At the population level, PT + AGA was the greatest contributor to newborn mortality (median PAR% 53.7, IQR 44.5-54.9). Mortality risk was highest among newborns born before 28 weeks (median RR 279.5, IQR 234.2-388.5) compared with babies born between 37 and 42 completed weeks or with a birthweight less than 1000 g (median RR 282.8, IQR 194.7-342.8) compared with those between 2500 g and 4000 g as a reference group.

CONCLUSION

Preterm newborn types were the most vulnerable, and associated with the highest mortality, particularly with co-existence of preterm and SGA. As PT + AGA is more prevalent, it is responsible for the greatest burden of neonatal deaths at population level.

Vulnerable newborn types: Analysis of population-based registries for 165 million births in 23 countries, 2000-2021

OBJECTIVE

To examine the prevalence of novel newborn types among 165 million live births in 23 countries from 2000 to 2021.

DESIGN

Population-based, multi-country analysis.

SETTING

National data systems in 23 middle- and high-income countries.

POPULATION

Liveborn infants.

METHODS

Country teams with high-quality data were invited to be part of the Vulnerable Newborn Measurement Collaboration. We classified live births by six newborn types based on gestational age information (preterm <37 weeks versus term ≥37 weeks) and size for gestational age defined as small (SGA, <10th centile), appropriate (10th-90th centiles), or large (LGA, >90th centile) for gestational age, according to INTERGROWTH-21st standards. We considered small newborn types of any combination of preterm or SGA, and term + LGA was considered large. Time trends were analysed using 3-year moving averages for small and large types.

MAIN OUTCOME MEASURES

Prevalence of six newborn types.

RESULTS

We analysed 165 017 419 live births and the median prevalence of small types was 11.7% - highest in Malaysia (26%) and Qatar (15.7%). Overall, 18.1% of newborns were large (term + LGA) and was highest in Estonia 28.8% and Denmark 25.9%. Time trends of small and large infants were relatively stable in most countries.

CONCLUSIONS

The distribution of newborn types varies across the 23 middle- and high-income countries. Small newborn types were highest in west Asian countries and large types were highest in Europe. To better understand the global patterns of these novel newborn types, more information is needed, especially from low- and middle-income countries.

Registration of a pregnant woman in the maternity hospital (optimally at 36th-37th weeks) at the Olomouc University Hospital in 2022

OBJECTIVE

The aim of the study was to analyse the results of the implementation of the new health service Registration of a pregnant woman in the maternity hospital (optimally at 36th-37th weeks) provided as part of outpatient/ambulatory health care at Olomouc University Hospital (OUH).

MATERIALS AND METHODS

A prospective cohort study. In 2022, a total of 2,271 women gave birth in OUH, and 2,010 of them were Registered in the maternity hospital, defined specific risks were identified and a pregnancy termination strategy was established/determined.

RESULTS

The health service was provided to 88.5% of women giving birth (2,010/2,271). The age of the mothers was 15-56 years (mean 31.3 years; median 31 years), their body mass index was 13.4-53.1 kg/m2 (mean 24.6 kg/m2; median 23.2 kg/m2). 43.6% of them (877/2,010) were Low-risk pregnancies and 56.4% (1,133/2,010) were Pregnancies with a defined specific risk. The most frequently identified risks were as follows: RhD negative blood group (18.4%), diabetes mellitus (13.9%), history of caesarean section (12.0%), hypertensive disorders (6.5%), small fetus/fetal growth restriction (6.3%), risk the development of hemolytic disease in the fetus and the newborn (2.5%), multiple pregnancy (1.6%), congenital malformation of the fetus (1.3%) and placentation disorders (0.5%). In 63.4% of them (1,275/2,010), the pregnancy termination strategy was determined by spontaneous vaginal delivery, in 18.0% (361/2,010) by pre-induction of vaginal delivery and in 14.2% (285/2,010) by caesarean section. In 4.4% (89/2,010) the health service was not implemented correctly because no strategy was established.

CONCLUSION

The implementation of the new health service will make it possible to replace activity (more frequent antenatal care contacts/visits and routine antenatal cardiotocography) with efficiency (risk identification, determination of the optimal strategy for outpatient/ambulatory antenatal care and timing and mode of delivery) and thereby provide better and safer health care (from a medical, organizational, legislative and economic points of view).

Incidence of spontaneous abortions and congenital anomalies in the vicinity of a uranium processing plant

OBJECTIVES

The exposure of embryos or foetuses to ionising radiation can cause serious detriments to health. Thus, an enhanced incidence of spontaneous abortions and congenital anomalies might be expected in the vicinity of a uranium processing plant. We analysed the situation in the vicinity of MAPE Mydlovary, a facility about 20 km from České Budějovice, South Bohemia, Czech Republic, which was in operation from 1963 to 1992.

METHODS

No relevant data are available for the period of operation of the uranium processing plant. Statistical data have only been collected since 1994. As sanitation work in the area was initiated at around that time and has yet to be completed, we considered a study of possible prenatal effects in the vicinity of MAPE Mydlovary to still be of interest. Data were provided by the Institute of Health Information and Statistics of the Czech Republic for the years 1994-2013.

RESULTS

We tested whether there are demonstrable, statistically significant differences between the microregions of the four closest villages (Mydlovary, Olešník, Zahájí, and Zliv), the District of České Budějovice, the South-Bohemian Region, and the Czech Republic.

CONCLUSIONS

No increase was found in the incidence of spontaneous abortions and congenital anomalies in the vicinity of this former uranium processing plant compared to the surrounding District of České Budějovice, the South Bohemian Region, or the Czech Republic as a whole.

Congenital anomalies in children born in the Czech Republic in 1994-2015

ÚVOD Populace je v sou&#269;asné vystavena r&#367;zným zevním vliv&#367;m, ze kterých mohou vyplývat i r&#367;zná zdravotní rizika. Jedním z mo&#382;ných je i riziko vzniku vrozené vady (VV). Z hlediska studia zdravotního stavu populace je d&#367;le&#382;itá znalost nejen pr&#367;m&#283;rných celkových incidencí VV, ale i p&#345;ípadných zm&#283;n t&#283;chto incidencí v pr&#367;b&#283;hu &#269;asu. Incidence VV je pova&#382;ována za jeden ze základních kvalitativních ukazatel&#367; popula&#269;ních i medicínských (1). Nelze opomenout ani hledání potenciálních rizik vedoucích ke zvý&#353;ené pravd&#283;podobnosti výskytu VV. T&#283;mito riziky mohou být ne&#382;ádoucí vlivy zevního prost&#345;edí nebo faktory biologicko-sociální (v&#283;k &#382;en, jejich onemocn&#283;ní aj). Podíl jednotlivých typ&#367; VV u narozených d&#283;tí se v &#269;ase m&#283;ní, obdobn&#283; jako struktura p&#345;í&#269;in úmrtí. Z hlediska epidemiologického je nutné hodnotit incidence VV a jejich zm&#283;ny p&#345;edev&#353;ím z pohledu jednotlivých diagnóz. B&#283;hem posledních let se intenzita VV v &#268;esku m&#283;nila. U n&#283;kterých typ&#367; se &#269;etnost v novorozenecké populaci sni&#382;uje díky úsp&#283;&#353;né prenatální diagnostice, u jiných diagnóz naopak &#269;etnost u narozených d&#283;tí stoupá (2). Krom&#283; prenatální diagnostiky se v&#353;ak na výsledné &#269;etnosti VV v populaci mohou uplat&#328;ovat i dal&#353;í vlivy. Jedním z nich m&#367;&#382;e být i zlep&#353;ení, zrychlení a zkvalitn&#283;ní postnatálních diagnostických mo&#382;ností - p&#345;edev&#353;ím zavedení a rozvoj ultrazvukové diagnostiky (3). Úsp&#283;&#353;nost prenatální diagnostiky a &#269;etnost VV u narozených jsou rovn&#283;&#382; významným ukazatelem prenatální a perinatální pé&#269;e, p&#345;e&#382;ívání d&#283;tí narozených s VV pak ukazatelem pé&#269;e postnatální (p&#345;edev&#353;ím neonatální a chirurgické). Registrace vrozených vad má v &#268;eské republice dlouhou tradici - Národní registr vrozených vad zahájil svou &#269;innost ji&#382; p&#345;ed více ne&#382; p&#367;lstoletím, v roce 1964 (4).   METODIKA Retrospektivní epidemiologická studie vyu&#382;ívá oficiální data z Národního registru vrozených vad vedeného v rámci Registru reproduk&#269;ního zdraví v Ústavu zdravotnických informací a statistiky &#268;R (ÚZIS). Analyzovány byly incidence jednotlivých diagnóz vrozených vad (kódy Q00-Q99) u narozených d&#283;tí z celého území &#268;eské republiky za &#269;asové období 1994-2015. Incidence VV byly analyzovány pro ob&#283; pohlaví, a to jak celkov&#283; (pro celou skupinu diagnóz VV), tak i dle základních diagnostických skupin Mezinárodní klasifikace nemocí (MKN).   VÝSLEDKY V období 1994-2015 se dle údaj&#367; ÚZIS &#268;R narodilo v &#268;eské republice celkem 87 359 d&#283;tí s vrozenou vadou zji&#353;t&#283;nou do 1 roku &#382;ivota. Z tohoto celkového po&#269;tu bylo 51 315 chlapc&#367; a 36 030 dívek. U 14 p&#345;ípad&#367; nebylo pohlaví známé / zji&#353;t&#283;no. Vývoj po&#269;tu diagnostikovaných p&#345;ípad&#367; ukazují p&#345;ehledn&#283; první t&#345;i grafy (obr. 1-3), zvlá&#353;&#357; pro chlapce, dívky a celkov&#283;. V relativních po&#269;tech to bylo za celé sledované období pr&#367;m&#283;rn&#283; 385,4 na 10 000 &#382;iv&#283; narozených d&#283;tí: nejmén&#283; 242,5 v roce 1994, nejvíce pak 448,3 v roce 2011. V p&#345;ípad&#283; &#382;iv&#283; narozených chlapc&#367; to bylo nejmén&#283; 263,6 v roce 1994, nejvíce pak 533,3 v roce 2011; pr&#367;m&#283;rná hodnota &#269;inila 440,6 na 10 000. U &#382;iv&#283; narozených dívek byla pr&#367;m&#283;rná hodnota za sledované období 327,1 na 10 000 ; nejni&#382;&#353;í hodnota 220,1 byla zaznamenána op&#283;t v roce 1994, nejvy&#353;&#353;í hodnota 380,9 v roce 2003. Grafy na obr. 4-6 ukazují relativní po&#269;ty na 10 000 &#382;iv&#283; narozených v pr&#367;b&#283;hu sledovaného období, op&#283;t zvlá&#353;&#357; pro chlapce, dívky a celkov&#283;. Dal&#353;í &#269;ást na&#353;í analýzy se v&#283;novala zm&#283;nám v pr&#367;b&#283;hu sledovaného období pro jednotlivé skupiny diagnóz dle rozd&#283;lení v Mezinárodní klasifikaci nemocí, 10. verze (tab. 1). various types of congenital anomalies are changing during the time according to different factors. Three main factors are methodical changes of the registration process, improvement of prenatal diagnostics and the real changes of incidences of selected diagnoses. While in the previous time period (till 1993) the registry included only selected diagnoses of congenital anomalies, in the new period (starting 1994) the registry includes all diagnoses of congenital anomalies from the ICD-10 classification. We can also see the difference in the incidences from 1994-1999 and 2000-2015 time period. The reason for this difference is the methodical change of registration, the Registry of congenital anomalies also receives the notifications about possible anomalies from the report of newborn (even when the report of congenital anomaly was not sent). As for the prenatal diagnostics - we may analyse possible changes of incidences - if the specific defect can be diagnosed prenatally.

[Current state of transvaginal meshes by resolution of pelvic organ prolapse]

OBJECTIVE

Treatment of pelvic organs prolapse with transvaginal mesh kits represents nowadays a widespread surgical method, which partially replaced classic operations due to high success rate and low count of recurrences. Just like any other surgical method, the placement of transvaginal mesh is linked with occurrence of complications. In this article we attempt to review the more and less known facts about trans-vaginal meshes, their efficacy, count of recurrence and the spectrum of complications and we try to compare this technique with traditional surgical methods used to treat pelvic organs prolapse (without graft materials).

DESIGN

Review.

SETTING

Department of Obstetrics and Gynecology, Regional hospital Mladá Boleslav a.s., Mladá Boleslav.

METHODS

Overview of the results of recent studies published in the Czech and English language in recent years.

RESULTS

Pelvic organ prolapse repair with vaginal mesh has generally lower count of relapse especially in patients with wide genital hiatal area and with major levator ani avulsion. The spectrum of complications differs from classical techniques because of the presence of synthetic nonabsorbable material. Some of the specific complications we did not encounter during classical operations include vaginal mesh erosion, infection of mesh associated with chronic pelvic pain, dyspareunia, protrusion of the mesh into the closest organs or the rejection and progressive extrusion of the mesh.

CONCLUSION

Primary enthusiasm has now been replaced with worries of major complications. Future tasks should therefore be aimed at minimizing the rate of complications associated with transvaginal meshes. Except using well-known and safe materials and providing specialized training of physicians for each mesh implantation technique, other precautions outlined in this article should help, such as a closer specification of indication for the application of transvaginal mesh.

[Mechanical loading of the human femoral neck]

PURPOSE OF THE STUDY

The aim of the study is to explain what is the actual loading of human proximal femur.

MATERIAL

Measuring of stress is based on 5 femurs of normal shape (bones obtained from dissection and ossuary). In order to determine the direction of the resultant force the authors used 30 ossuary bones of different age but of analogical shape.

METHODS

By means of their own graphic method the authors identified the direction of appositional growth of femoral neck which contains with the longitudinal diaphyseal axis the angle of 26 degrees (alpha angle). The value of the angle is identical with the direction of the resultant force acting on the femoral head in vivo. Tensometric method was used for the measuring of stress on the medial and lateral surfaces of femoral neck during loading in direction of the determined resultant force. Linear strain gauges of Hottinger type were used for the measuring and Instron apparatus was applied for biomechanical analysis in which femoral heads were loaded by a standard force of 50 kg, first in the direction of femoral diaphyseal axis and then gradually (always by 5 degrees) in the divergence from the diaphyseal axis up to 50 degrees.

RESULTS

Appositional growth of femoral neck with regard to the longitudinal diaphyseal axis is progressing under the alpha angle (alpha = 26 degrees), which corresponds to the direction of the resultant force. The value of the compression stress on the medial surface of the neck ranged between--165 and -300 microstrain (mean value -239 microstrain). On the lateral surface there is a tension stress ranging between +20 up to +140 microstrain (main value +64 microstrain). The ratio of stress on both sides (surfaces) was 3.8:1. The point of zero stress is located in the lateral part of the neck, i.e. in the area of lateral trajectorial system of cancellous bone.

DISCUSSION

The method of measuring of the direction of the resultant force on the basis of the bone development (on the basis of superposition of successive growth stages) is despite certain inaccuracies a correct procedure. The alpha angle (alpha = 26 degrees) identified by the authors corresponds with Pauwels' calculation (24 degrees) and Bergman's findings (22 degrees up to 27 degrees). The identified values of stress show that the opinion on a purely axial loading of the neck is wrong and has to be corrected. Femur is not exposed in the frontal plane to the action of the resultant force only in one direction as supposed e.g. by Pauwels but the direction of the resultant force oscillates within a limited extent from different directions. It means that the lateral wall of femoral neck is exposed to alternating both tensile and compression loading.

CONCLUSION

The presented work allows to specify the opinions on the way of loading of human proximal femur. Our experiments have shown that apart from axial pressure the femoral neck is exposed also to bending forces. This way of loading also corresponds with the oval shape and thickened medial wall of the neck.

On the mechanical function of tendon

A mesoscopic approach is followed for mathematical modelling of the specific deformation properties of tendon. The approach starts from our general concept of modelling mechanical behaviour of heterogeneous media and assumes that the structure of tendon is optimized in such a way that it enables its adjacent muscle to work with a constant performance in the course of increasing loading (acting like a gearbox in a car). The model based on this assumption gives results that are in a very good accordance with observed properties of tendons. Clinical experience reveals that if this function of tendon is violated pathological changes appear in the respective muscle. RELEVANCE: Clarification and mathematical modelling of the mechanical function of tendon is of intellectual interest in its own right, but it is important also for cautioning surgeons against unnecessary violation of this function, and for tissue engineering aspects if tendon must be replaced.

[Ceramic Materials and their Use in Surgery.]

The authors discuss the use of ceramic materials in clinical practice, in particular in bone surgery. Biocompatibility usually conceived in the direction synthetic material-living tissue is analyzed in the reverse direction and the concequences of this combination on the reliability and life span of the implanted ceramics are given. The authors outline their ideas on the development of implant materials of a new generation based on comparison with the structure and mechanical properties of compact bone. Key words: high-performance ceramics, compatibility, reliability and lifetime of ceramics.

A structural mathematical model for the viscoelastic anisotropic behaviour of trabecular bone

The presented paper is based on the conclusions of the preceding paper (1). On the basis of a general theoretical approach to the mechanics of heterogeneous materials published earlier / (2) , (3) , (4) / macroscopic constitutive equation of trabecular bone is deduced from the description of its microstructure. For the behaviour in physiological limits trabeculae are described as elastic and the remaining material constituent as a Maxwell body. The resulting macroscopic constitutive equation comprehends tensorial internal variables and the parameters appearing in it are the constants of the material constituents constitutive equations, the respective volume fractions and special structural parameters descriptive of the geometry of composition. The system of the trabeculae as well as the system of the remaining constituent of the composite are considered to be interconnected - continuous. Explicite formulae are given for the case of transverse isotropy, but the extension to more general cases of anisotropy is well possible. The procedure of identification of the model parameters is shown and a numerical example calculated.