Obstetric analgesia: a comparison of patient-controlled meperidine, remifentanil, and fentanyl in labour.

BACKGROUND: To compare the analgesic efficacy of remifentanil with meperidine and fentanyl in a patient-controlled setting (patient-controlled analgesia, PCA). METHODS: Parturients (n=159) were randomly assigned to receive remifentanil (n=52), meperidine (n=53), or fentanyl (n=54). Pain scores and an observer sedation scores were assessed hourly. Fetal outcome was evaluated with Apgar score, cord blood gas analysis and the Neurologic and Adaptive Capacity Score. RESULTS: Pain scores decreased in all groups, the decrease varying from mild to moderate, average pain scores remaining above 4.5 cm in all groups. Remifentanil PCA was associated with the greatest decrease in pain scores, but the difference was significant only at 1 h. Pain scores returned towards baseline over time; 3 h after the initiation of treatment, pain scores no longer differed significantly from baseline values in any of the groups. Significantly more parturients receiving meperidine crossed over to epidural analgesia. Overall satisfaction scores were higher with remifentanil, but remifentanil produced more sedation and itching. More periods of desaturation (Sa(o(2)) <95%) were observed during administration of remifentanil and fentanyl. There were no significant differences in fetal outcome between the three groups. CONCLUSIONS: The efficacy of meperidine, fentanyl, and remifentanil PCA for labour analgesia varied from mild to moderate. Remifentanil PCA provided better analgesia than meperidine and fentanyl PCA, but only during the first hour of treatment. In all groups, pain scores returned to pre-treatment values within 3 h after the initiation of treatment.

Mortality in very preterm and very low birth weight infants according to place of birth and level of care: results of a national collaborative survey of preterm and very low birth weight infants in The Netherlands.

As part of a collaborative project in the Netherlands in 1983, for which data were collected on 1,338 newborn infants (less than 32 weeks' gestation and/or less than 1,500 g birth weight), all infants were assigned to one of three levels of care according to hospital of birth. Considerable centralization was achieved by antenatal and neonatal transport. Although the uncorrected mortality rates were similar, the mortality odds (adjusted for four and 22 potential confounding perinatal factors, respectively) were significantly higher in level 1 and level 2 hospitals compared with level 3 hospitals (tertiary perinatal care centers). By extending the facilities for full perinatal intensive care in level 3 centers and thus providing optimal care for all such infants, the overall mortality rate is expected to decrease further.

Similar myeloid recovery despite superior overall engraftment in NOD/SCID mice after transplantation of human CD34(+) cells from umbilical cord blood as compared to adult sources.

Umbilical cord blood (UCB), bone marrow (BM) and mobilized peripheral blood (mPB) are used as sources of hematopoietic stem cells for transplantation. The NOD/SCID mouse model was used to compare the lineage-specific repopulating potential of CD34(+) cells derived from these sources. Six to 8 weeks after transplantation, blood, BM, spleen, liver and thymus, were harvested, and analyzed by flow cytometry using CD34, CD45, myeloid, and lymphoid lineage-specific antibodies. Fifty percent engraftment of human cells in bone marrow of mice was estimated to be reached with 0.55 x 10(6) CD34(+) UCB cells or with 7.9 x 10(6) CD34(+) cells from adult sources, illustrating a 10-fold superiority of UCB CD34(+) cells to engraft NOD/SCID mice. Lineage-specific characterization of engrafted human cells showed that the high engraftment potential of CD34(+) cells from UCB was due to a preferential B cell development (2-81%). In contrast, comparable percentages of myeloid cells were found following transplantation of CD34(+) cells from UCB, BM and mPB (1-38%), and occurred at significant levels only at relatively high doses. Since the CD34 content of UCB transplants is usually at least one log lower than of transplant from adult sources, these results correspond to the clinical findings with UCB transplantation showing a relatively high overall engraftment, but delayed myeloid recovery.

Maternal and neonatal transport: results of a national collaborative survey of preterm and very low birth weight infants in The Netherlands.

In a Dutch national collaborative study on 1338 infants, born in 1983 after a pregnancy of less than 32 weeks and/or with a birth weight of less than 1500 g, a comparison was made between maternal transport to university hospital perinatal centers and delivery in local or regional general hospitals and between neonatal transport to university hospital neonatal centers and treatment in local or regional general hospitals. The risk of mortality was investigated by means of logistic regression analysis including 27 perinatal risk factors as confounding variables. The results showed that infants born after maternal transport to centers had a significantly lower mortality risk. Infants treated in centers after neonatal transport had a lower mortality risk as well, but this was not statistically significant at a .05 level. The results of the study confirm that referral by maternal transport to level III centers offers the best prospects for high-risk preterm infants.

Acute polyhydramnios associated with fetal hepatoblastoma.

A 28-yr-old gravida II mother presented at 29 wk gestation with acute polyhydramnios. The most common causes for polyhydramnios were excluded and onset of preterm labor at 31 wk prevented further studies. Tocolysis failed and a severely asphyxiated boy was born. He had a very distended abdomen with a 7 cm hepatomegaly and was in shock. No other physical abnormalities were found. The child died 15 min after birth. At post mortem examination a fetal type hepatoblastoma was detected. Duodenal obstruction due to the liver tumor might have caused the polyhydramnios.

Maternal hypertension and very preterm infants' mortality and handicaps.

In a nationwide survey on liveborn very preterm and/or very low birthweight infants in The Netherlands, mortality and handicaps at the corrected age of 2 years were studied in infants born to mothers with or without hypertensive disorders during pregnancy. The neonatal and in-hospital mortality was significantly lower in infants born to hypertensive mothers. In surviving infants, a similar handicap rate was found at the corrected age of 2 years for both groups.

[Hemolytic disease in a newborn infant caused by rare maternal anti-erythrocyte antibodies and exchange transfusion with maternal blood frozen earlier]. / Hemolytische ziekte bij een pasgeborene door zeldzame maternale anti-erytrocyten-antistoffen, en wisseltransfusie met eerder ingevroren maternaal bloed.

After a pregnancy of 31 weeks and 4 days a pale baby girl was born with mild oedema, severe anaemia (4.2 mmol/l), increased normoblast count and hyperbilirubinaemia, indicating a blood group antagonism. This was caused by very rare irregular antibodies with the specificity anti-U. These antibodies had been demonstrated in the mother before, after earlier transfusions with erythrocytes. At that time autologous blood was stored at -70 degrees C in the Central Laboratory of the Dutch Red Cross in Amsterdam, because U negative donors are hard to find. One of these units was used for an exchange transfusion given to the baby, who recovered well. This case study underlines the necessity of screening for presence of irregular antibodies during pregnancy. A national registration of patients with antibodies against erythrocytes is recommended.

[Mortality risk after intrauterine and after neonatal transport]. / Sterftekans na intra-uterien en neonataal transport.

In a Dutch national collaborative study of 1338 newborn infants born in 1983 with a gestational age of less than 32 weeks and (or) a birth weight of less than 1500 g, a comparison was made of maternal transport to university perinatal centres and delivery in local general hospitals on the one hand, and neonatal transport to those centres and treatment in regional general hospitals on the other. The mortality risk was investigated by means of logistic regression analysis. The results show that maternal transport was accompanied by a statistically significantly lower mortality risk. The mortality risk after neonatal transport, compared with that after treatment in regional hospitals, was also lower although not significantly. Mortality risk after neonatal transport was significantly associated with increasing transportation distance. The results of the study confirm that referral by maternal transport offers the best prospects for high risk preterm babies.

[Birth weight percentiles of premature infants needs to be updated]. / Percentielgrenzen voor geboortegewicht van vroeggeborenen moeten worden herzien.

OBJECTIVE: To analyse whether the conventional so-called Kloosterman charts for birthweight of preterm infants based on data from 1931-1965 are still valid. DESIGN: Descriptive investigation. LOCATION: The Netherlands. METHOD: Data were obtained from the 'project of the premature and small for gestational age' (POPS) survey in 1983. The population consisted of 855 Caucasian infants born after a pregnancy of 24-31 weeks. RESULTS: In nearly all gestational age categories the percentages of small-for-gestational age infants were higher than the 10% they should have been by definition; the percentages of large-for-gestational age infants were much lower than 10%. After exclusion of elective births the percentages remained different. CONCLUSION: These shifts in the birthweight distribution are probably the result of changes in obstetrics. The birthweight percentiles for preterm births will have to be updated.

[Increase in perinatal referral to regional centers of premature birth in The Netherlands: comparison 1983 and 1993]. / Toename van perinatale verwijzing naar regionale centra bij vroeggeboorte in Nederland: vergelijking van 1983 en 1993.

OBJECTIVE: To determine changes in referral of preterm newborns. DESIGN: Descriptive. SETTING: Foundation for Perinatal Epidemiology the Netherlands, Leiden. METHODS: Data regarding hospital of birth, referral, need of intensive care and mortality of the infants < 32 weeks and (or) < 1500 g birth weight born in 1993 from the National Neonatology Register were supplemented with data from a questionnaire for hospitals not included in the register. The data were compared with those of similar infants from the 'Project on preterm and small for gestational age', born in 1983. RESULTS: In 1983, 61% of the preterm infants were treated in a perinatal centre: 39% were not referred. In 1993 these numbers were 89% and 11%, respectively. The contribution of antenatal referral increased from 29% to 47% while that of postnatal referral decreased from 41% to 25%. Mortality decreased from 25.4% in 1983 to 14.3% in 1993. CONCLUSION: Regionalization of high risk perinatal care resulted in concentration of care for preterm infants. At the same time, in-hospital mortality decreased by almost 50%.

A randomised comparison of intravenous remifentanil patient-controlled analgesia with epidural ropivacaine/sufentanil during labour.

BACKGROUND: The µ-opioid agonist remifentanil has a rapid onset and offset and a short half-life making it an attractive option for intravenous patient-controlled labour analgesia. We aimed to compare the efficacy of intravenous remifentanil patient-controlled analgesia with epidural ropivacaine/sufentanil during labour. METHODS: Parturients were randomly assigned to receive intravenous patient-controlled analgesia with remifentanil (n=10) or epidural analgesia (n=10). Pain and satisfaction scores were assessed every hour by means of visual analogue scale, together with an observer sedation score. Side effects and neonatal outcome were noted. RESULTS: After one hour, visual analogue pain scores had decreased significantly in both groups (remifentanil: -3.8 ± 2.6, P<0.01; epidural -6.7 ± 2.0, P<0.01). The decrease in pain scores in the epidural group was significantly greater than the remifentanil group at all time intervals. The decrease in pain scores was sustained in the epidural group whereas in the remifentanil group pain scores increased over time. Oxygen saturation was significantly lower in the remifentanil group after one hour of treatment compared to the epidural group (95.2 ± 2.4% vs. 99.0 ± 1.1%, P<0.01). Patient satisfaction scores during and after delivery were similar in both groups. No differences were found in neonatal outcome. CONCLUSIONS: In the 20 patients recruited to this study, pain relief in labour with epidural ropivacaine/sufentanil was more effective than with intravenous remifentanil patient-controlled analgesia.

Prenatal ultrasonic diagnosis of familial asymmetric septal hypertrophy.

Hypertrophic cardiomyopathy usually manifests clinically in the second or third decade of life. Two dimensional echocardiography is a reliable indicator of the presence of the disease. This technique is of use in the screening of fetuses at risk for familial cardiomyopathy. This report describes the prenatal echocardiographic detection of hypertrophic cardiomyopathy in the fetus of a mother with hypertrophic cardiomyopathy localized to the apical region of the left ventricle.

Neonatal mortality risk in relation to gestational age and birthweight. Results of a national survey of preterm and very-low-birthweight infants in the Netherlands.

In a cohort of 1338 very preterm and/or very-low-birthweight infants, representing 94% of all infants born alive after less than 32 weeks' gestation or weighing less than 1500 g in the Netherlands in 1983, the neonatal mortality rate was 233 per 1000. In these infants, the best obstetric estimate of gestational age was a better predictor of neonatal mortality than birthweight. In such pregnancies, careful obstetric assessment of gestational age seems to be a more accurate basis for clinical decisions and management than the expected birthweight.

The male disadvantage in very low birthweight infants: does it really exist?

In a nationwide collaborative study in the Netherlands, perinatal and follow up data were collected on 1338 liveborn very preterm (less than 32 weeks) and/or very low birthweight (VLBW) infants (less than 1500 g). In this group, the mortality risk was similar for both male and female infants. The handicap risk, however, was significantly greater for boys than for girls. This finding could not be explained as being due to the well-known delay in lung maturation in male infants as in idiopathic respiratory distress syndrome and need of assisted ventilation.