Pediatric admissions that include intensive care: a population-based study.

BACKGROUND: Pediatric admissions to intensive care outside children's hospitals are generally excluded from registry-based studies. This study compares pediatric admission to specialist pediatric intensive care units (PICU) with pediatric admissions to intensive care units (ICU) in general hospitals in an Australian population. METHODS: We undertook a population-based record linkage cohort study utilizing longitudinally-linked hospital and death data for pediatric hospitalization from New South Wales, Australia, 2010-2013. The study population included all new pediatric, post-neonatal hospital admissions that included time in ICU (excluding neonatal ICU). RESULTS: Of 498,466 pediatric hospitalizations, 7525 (1.5%) included time in an intensive care unit - 93.7% to PICU and 6.3% to ICU in a general (non-PICU) hospital. Non-PICU admissions were of older children, in rural areas, with shorter stays in ICU, more likely admitted for acute conditions such as asthma, injury or diabetes, and less likely to have chronic conditions, receive continuous ventilatory support, blood transfusion, parenteral nutrition or die. CONCLUSIONS: A substantial proportion of children are admitted to ICUs in general hospitals. A comprehensive overview of pediatric ICU admissions includes these admissions and the context of the total hospitalization.

Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised controlled trial.

BACKGROUND: Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of prematurity. The balance of risks is unclear. We aimed to establish whether immediate birth in singleton pregnancies with ruptured membranes close to term reduces neonatal infection without increasing other morbidity. METHODS: The PPROMT trial was a multicentre randomised controlled trial done at 65 centres across 11 countries. Women aged over 16 years with singleton pregnancies and ruptured membranes before the onset of labour between 34 weeks and 36 weeks and 6 days weeks who had no signs of infection were included. Women were randomly assigned (1:1) by a computer-generated randomisation schedule with variable block sizes, stratified by centre, to immediate delivery or expectant management. The primary outcome was the incidence of neonatal sepsis. Secondary infant outcomes included a composite neonatal morbidity and mortality indicator (ie, sepsis, mechanical ventilation ≥24 h, stillbirth, or neonatal death); respiratory distress syndrome; any mechanical ventilation; and duration of stay in a neonatal intensive or special care unit. Secondary maternal outcomes included antepartum or intrapartum haemorrhage, intrapartum fever, postpartum treatment with antibiotics, and mode of delivery. Women and caregivers could not be masked, but those adjudicating on the primary outcome were masked to group allocation. Analyses were by intention to treat. This trial is registered with the International Clinical Trials Registry, number ISRCTN44485060. FINDINGS: Between May 28, 2004, and June 30, 2013, 1839 women were recruited and randomly assigned: 924 to the immediate birth group and 915 to the expectant management group. One woman in the immediate birth group and three in the expectant group were excluded from the primary analyses. Neonatal sepsis occurred in 23 (2%) of 923 neonates whose mothers were assigned to immediate birth and 29 (3%) of 912 neonates of mothers assigned to expectant management (relative risk [RR] 0·8, 95% CI 0·5-1·3; p=0·37). The composite secondary outcome of neonatal morbidity and mortality occurred in 73 (8%) of 923 neonates of mothers assigned to immediate delivery and 61 (7%) of 911 neonates of mothers assigned to expectant management (RR 1·2, 95% CI 0·9-1·6; p=0·32). However, neonates born to mothers in the immediate delivery group had increased rates of respiratory distress (76 [8%] of 919 vs 47 [5%] of 910, RR 1·6, 95% CI 1·1-2·30; p=0·008) and any mechanical ventilation (114 [12%] of 923 vs 83 [9%] of 912, RR 1·4, 95% CI 1·0-1·8; p=0·02) and spent more time in intensive care (median 4·0 days [IQR 0·0-10·0] vs 2·0 days [0·0-7·0]; p<0·0001) compared with neonates born to mothers in the expectant management group. Compared with women assigned to the immediate delivery group, those assigned to the expectant management group had higher risks of antepartum or intrapartum haemorrhage (RR 0·6, 95% CI 0·4-0·9), intrapartum fever (0·4, 0·2-0·9), and use of postpartum antibiotics (0·8, 0·7-1·0), and longer hospital stay (p<0·0001), but a lower risk of caesarean delivery (RR 1·4, 95% CI 1·2-1·7). INTERPRETATION: In the absence of overt signs of infection or fetal compromise, a policy of expectant management with appropriate surveillance of maternal and fetal wellbeing should be followed in pregnant women who present with ruptured membranes close to term. FUNDING: Australian National Health and Medical Research Council, the Women's and Children's Hospital Foundation, and The University of Sydney.

Long-term outcomes for large for gestational age infants born at term.

AIM: Large for gestational age (LGA) babies have increased risks for short-term outcomes such as shoulder dystocia, neonatal hypoglycaemia and longer hospital stay. Little is known of long-term health, development and educational outcomes of LGA babies. The aim of this study was to determine the long-term health, mortality, development and educational outcomes for infants born LGA at term. METHODS: A population-based record linkage study of live singletons born at term (37-41 weeks of gestation) in New South Wales, Australia, from 2001 to 2006. RESULTS: This study compared 49 439 LGA (>90th percentile for birthweight, gestational age and sex) and 400 418 appropriate size for gestational age (AGA; 10th-90th percentile) infants. LGA infants had increased risk of birth and neonatal outcomes and hospitalisations, for brachial plexus injury after the neonatal period, and for all causes from 1 to 5 years of age. There were no differences in mortality up to 5 years of age or hospitalisations for type 1 diabetes in childhood. LGA infants had lower rates of developmental vulnerability (in kindergarten) and showed a significant trend (χ2 for trend <0.0001) to fewer low scores and more high scores in reading and numeracy (in Year 3) compared with AGA. After adjusting for potential confounders, only the relative risk for higher reading scores was statistically significant. CONCLUSIONS: LGA infants show positive long-term health, development and educational outcomes. Concerns for LGA infants still remain in the perinatal period as a result of birth trauma; however, these complications usually do not persist in postnatal and early childhood.

Cervical cerclage placed before 14 weeks gestation in women with one previous midtrimester loss: A population-based cohort study.

BACKGROUND: Cervical cerclage is used in an attempt to reduce recurrence risk of preterm birth, but evidence for use is limited. AIMS: To compare pregnancy outcomes among women with a single previous midtrimester delivery when managed with or without a cervical cerclage. MATERIALS AND METHODS: Population-based cohort study of all women in New South Wales, Australia with a singleton pregnancy ending in birth/miscarriage ≥14 and <28 weeks, between 2003 and 2011. Modified Poisson regression was used to compare outcomes in the next subsequent pregnancy, for women with a cerclage inserted <14 weeks, and those without cerclage. The primary outcome was gestational age <37 weeks at birth/miscarriage in the next pregnancy. Secondary outcomes included: maternal morbidity, preterm prelabour rupture of membranes (PPROM), stillbirth/neonatal death and composite neonatal morbidity for liveborn infants ≥28 weeks. Adjusted risk ratios (ARR) and 95% confidence intervals (CI) were determined. RESULTS: Five thousand, six hundred and ninety-eight births/miscarriages were potential index deliveries. Of these, 2175 women had an eligible subsequent pregnancy: 108 received cerclage at <14 weeks gestation, 2067 did not. Women with cerclage were significantly more likely to deliver <37 weeks than those without (39.8% vs 19.3%, ARR 1.92, 95% CI 1.48-2.48), and had increased risks of PPROM (ARR 4.38, 95% CI 2.62-7.32) and stillbirth/neonatal death (ARR 2.20, 95% CI 1.02-4.73). Following cerclage, liveborn infants ≥28 weeks had double the risk of severe morbidity (ARR 2.54, 95% CI 1.55-4.16). CONCLUSIONS: In women with a single previous midtrimester delivery, cervical cerclage <14 weeks gestation in subsequent pregnancy was associated with worse pregnancy outcomes.

Early-onset preeclampsia appears to discourage subsequent pregnancy but the risks may be overestimated.

BACKGROUND: Early-onset preeclampsia is associated with adverse maternal and perinatal outcomes. For women who consider another pregnancy after one complicated by early-onset preeclampsia, the likelihood of recurrence and the subsequent pregnancy outcome for themselves and their babies are pertinent considerations. OBJECTIVES: The purpose of this study was to determine the subsequent pregnancy rate after a nulliparous pregnancy that was complicated by early-onset preeclampsia and among those who have a subsequent pregnancy, the risk of recurrence by gestational week, and adverse pregnancy outcomes. STUDY DESIGN: This was a population-based record linkage cohort study. The study population included nulliparous women with a singleton pregnancy and early-onset preeclampsia (<34 weeks gestation) who gave birth in New South Wales Australia from 2001-2010 (the index birth), with follow-up data for a subsequent birth through 2012. Early-onset in the index birth was further categorized as <28 vs 28-33 weeks gestation. Subsequent pregnancy outcomes that were assessed included the pregnancy rate, preeclampsia recurrence, and maternal and perinatal morbidity and mortality rates. The risk of preeclampsia necessitating delivery at each gestational week for women who were at risk was plotted, and the net gain or loss of gestational age when comparing the index with the subsequent pregnancy was calculated. RESULTS: Among 361,031 nulliparous women with singleton pregnancies, 1473 (0.4%) had early-onset preeclampsia. Women with early-onset preeclampsia in their first pregnancy had a lower subsequent pregnancy rate (59.7%) than women without preeclampsia (67.7%). Of the 758 women with a subsequent singleton birth, 256 (33.8%) experienced preeclampsia in the next pregnancy; 57 women (7.5%) with recurrent early-onset preeclampsia were included. Cumulative rates of preeclampsia in the subsequent pregnancy were higher at every gestation from 23 weeks gestation when the index birth was <28 weeks compared with 28-33 weeks gestation. The cumulative rate and gestation-specific risk of recurrent preeclampsia rose most steeply at 32-38 weeks gestation. Most women (94.6%) progressed to a later gestational age in their subsequent pregnancy. The median overall increase in gestational age at delivery was 6 weeks (interquartile range, 4-8); among women with recurrent preeclampsia, the median increase was 5 weeks (interquartile range, 2-7). Women with index birth <28 weeks gestation compared with 28-33 weeks gestation were more likely to deliver preterm (38.8% vs 28.7%; relative risk, 1.35; 95% confidence interval, 1.04-1.75) and have a perinatal death (4.3% vs 1.2%; relative risk, 3.46; 95% confidence interval, 1.15-10.39) at the subsequent birth, but live born infants had similar rates of severe morbidity (17.1% vs 15.0%; relative risk, 1.14; 95% confidence interval, 0.73-1.79). CONCLUSION: Women with early-onset preeclampsia in a first pregnancy appear less likely than women without preeclampsia to have a subsequent pregnancy. Maternal and perinatal outcomes in the subsequent pregnancy are generally better than in the first; most women will not have recurrent preeclampsia, and those who do usually will give birth at a greater gestational age compared with their index birth.

Reduced breast milk feeding subsequent to cosmetic breast augmentation surgery.

OBJECTIVE: To determine the effect of cosmetic breast augmentation on subsequent infant feeding. PARTICIPANTS, DESIGN AND SETTING: Population-based record linkage study of women giving birth in New South Wales, January 2006 - December 2011. Birth records were linked longitudinally to maternal hospitalisations up to 11 years before birth. Breast augmentation was identified by surgical procedure codes in hospital records. MAIN OUTCOME MEASURES: Any breast milk feeding at discharge from birth care, and among infants receiving any breast milk, exclusive breast milk feeding. The before-and-after effect of breast augmentation was assessed among women who had the surgery between births. RESULTS: Among 378 389 women who gave birth in the study period, 892 (0.2%) had prior breast augmentation. Among women with breast augmentation, 705 (79%) provided any breast milk to their infant at discharge, compared with 89% among women without augmentation. After adjusting for sociodemographic and pregnancy factors, infants of women with breast augmentation were less likely to receive breast milk at discharge than infants of women without augmentation (adjusted relative risk [ARR], 0.90; 95% CI, 0.87-0.93). However, infants receiving breast milk were not more or less likely to receive breast milk exclusively (ARR, 0.99; 95% CI, 0.97-1.01). Women with augmentation surgery between births changed their breastfeeding behaviour (reduced rates), while those with no augmentation or augmentation before both births did not. CONCLUSIONS: Reduced rates of breast milk feeding among women who have undergone breast augmentation underscore the importance of identifying, supporting and encouraging women who are vulnerable to a lower likelihood of breastfeeding.

Rate of spontaneous onset of labour before planned repeat caesarean section at term.

BACKGROUND: Guidelines recommend that, in the absence of compelling medical indications (low risk) elective caesarean section should occur after 38 completed weeks gestation. However, implementation of these guidelines will mean some women go into labour before the planned date resulting in an intrapartum caesarean section. The aim of this study was to determine the rate at which low-risk women planned for repeat caesarean section go into spontaneous labour before 39 weeks. METHODS: We conducted a population-based cohort study of women who were planned to have an elective repeat caesarean section (ERCS) at 39-41 weeks gestation in New South Wales Australia, 2007-2010. Labour, delivery and health outcome information was obtained from linked birth and hospital records for the entire population. Women with no pre-existing medical or pregnancy complications were categorized as 'low risk'. The rate of spontaneous labour before 39 weeks was determined and variation in the rate for subgroups of women was examined using univariate and multivariate analysis. RESULTS: Of 32,934 women who had ERCS as the reported indication for caesarean section, 17,314 (52.6%) were categorised as 'low-risk'. Of these women, 1,473 (8.5% or 1 in 12) had spontaneous labour or prelabour rupture of the membranes before 39 weeks resulting in an intrapartum caesarean section. However the risk of labour <39 weeks varied depending on previous delivery history: 25% (1 in 4) for those with spontaneous preterm labour in a prior pregnancy; 15% (1 in 7) for women with a prior planned preterm birth (by labour induction or prelabour caesarean) and 6% (1 in 17) among those who had only previously had a planned caesarean section at term. Smoking in pregnancy was also associated with spontaneous labour. Women with spontaneous labour prior to a planned CS in the index pregnancy were at increased risk of out-of-hours delivery, and maternal and neonatal morbidity. CONCLUSIONS: These findings allow clinicians to more accurately determine the likelihood that a planned caesarean section may become an intrapartum caesarean section, and to advise their patients accordingly.

Second pregnancy outcomes for women with systemic lupus erythematosus.

BACKGROUND: Systemic lupus erythematosus (SLE) is associated with adverse pregnancy outcomes overall. OBJECTIVE: To examine the outcomes for women with SLE in a pregnancy subsequent to a first birth with an adverse outcome. METHODS: A population-based cohort study was carried out of 794 577 deliveries to 532 612 women giving birth in New South Wales, Australia from 2001 to 2009. Data were obtained from longitudinally linked birth records and hospital records. RESULTS: 675 women had a diagnosis of SLE in the study period (prevalence 127 per 100 000 childbearing women). Of 177 women who had a first nulliparous birth and subsequent pregnancy, 10 (5.6%) had a perinatal death in the first pregnancy, and of these women, 9 (90%) had a baby discharged home alive in the second pregnancy. Of the 167 women whose first-birth infants survived, second pregnancy outcomes included: 18 (11%) admission for spontaneous abortion, 1 perinatal death (0.6%) and 148 (89%) infants discharged home. Two women had a thromboembolic event in their first pregnancy but had no thromboembolic event in the second. Two women had thromboembolic events in second pregnancies only. CONCLUSION: Women with SLE are at high risk of adverse pregnancy outcomes. However, those who have a perinatal death in their first pregnancy can expect a live birth for a subsequent pregnancy.

Reducing caesarean section rates--no easy task.

To identify the greatest potential for reducing overall caesarean delivery rates, we used longitudinally linked data for women with consecutive births 2001-2009 to examine the likely impact of hypothetical risk-based scenarios. Among women with a first birth, singleton, vertex-presenting fetus at term, increasing the vaginal birth rate following induction of labour by 20% potentially has greatest impact, with a 12.1% relative decrease in the overall caesarean rate. The potential relative decrease in other scenarios ranged from 0.8 to 5.9%.

Quality of data in perinatal population health databases: a systematic review.

BACKGROUND: Administrative or population health datasets (PHDS) are increasingly being used for research related to maternal and infant health. However, the accuracy and completeness of the information in the PHDS is important to ensure validity of the results of this research. OBJECTIVE: To compile and review studies that validate the reporting of conditions and procedures related to pregnancy, childbirth, and newborns and provide a tool of reference for researchers. METHODS: A systematic search was conducted of Medline and EMBASE databases to find studies that validated routinely collected datasets containing diagnoses and procedures related to pregnancy, childbirth, and newborns. To be included datasets had to be validated against a gold standard, such as review of medical records, maternal interview or survey, specialized register, or laboratory data. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and/or κ statistic for each diagnosis or procedure code were calculated. RESULTS: Forty-three validation studies were included. Under-enumeration was common, with the level of ascertainment increasing as time from diagnosis/procedure to birth decreased. Most conditions and procedures had high specificities indicating few false positives, and procedures were more accurately reported than diagnoses. Hospital discharge data were generally more accurate than birth data, however identifying cases from more than 1 dataset further increased ascertainment. CONCLUSIONS: This comprehensive collection of validation studies summarizing the quality of perinatal population data will be an invaluable resource to all researchers working with PHDS.

Trends in planned early birth: a population-based study.

OBJECTIVE: The purpose of this study was to describe trends and outcomes of planned births. STUDY DESIGN: Data from linked birth and hospital records for 779,521 singleton births at ≥33 weeks' gestation from 2001-2009 were used to determine trends in planned births (prelabor cesarean section and labor inductions). Adverse outcomes were composite indicators of maternal and neonatal morbidity/death. RESULTS: From 2001-2009, there were increases in labor inductions and prelabor cesarean deliveries at <40 weeks' gestation, but no decrease in the stillbirth rate (trend P = .34). By 2009, 14.9% of live births at ≥33 weeks' gestation were prelabor cesarean deliveries before the due date; 11.4% were inductions. As planned births increased, maternal risks shifted, which included a decline in inductions with maternal hypertension from 31.9-23.9%. Earlier birth was contemporaneous with increases (trend P < .001) in neonatal and maternal morbidity rates from 3.0-3.2% and 1.1-1.5%, respectively. CONCLUSION: Planned birth before the due date is increasing without a contemporaneous reduction of stillbirths.

Incidence of severe adverse neonatal outcomes: use of a composite indicator in a population cohort.

The aim was to develop a composite outcome indicator to identify infants with severe adverse outcomes in routinely collected population health datasets, and assess the indicator's association with readmission and infant mortality rates. A comprehensive list of diagnoses and procedures indicative of serious neonatal morbidity was compiled based on literature review, validation studies and expert consultation. Relevant diagnoses and procedures indicative of severe morbidity that are reliably reported were analysed and reviewed, and the neonatal adverse outcome indicator (NAOI) was refined. Data were obtained from linked birth and hospital data for 516,843 liveborn infants ≥24 weeks gestation, in New South Wales, Australia from 2001 to 2006. Face validity of the indicator was examined by calculating the relative risks (and 95% CI) of hospital readmission or death in the first year of life of those infants identified by the NAOI. Overall 4.6% of all infants had one or more conditions included in the NAOI; 35.4% of preterm infants and 2.4% of term infants. Infants identified by the composite indicator were 10 times more likely to die in the first year of life and twice as likely to be readmitted to hospital in the first year of life compared to infants not identified by the NAOI. The NAOI can reliably identify infants with a severe adverse neonatal outcome and can be used to monitor trends, assess obstetric and neonatal interventions and the quality of perinatal care in a uniform and cost-effective way.

Hospital data reporting on postpartum hemorrhage: under-estimates recurrence and over-estimates the contribution of uterine atony.

This study aimed to explore whether recording of a prior adverse pregnancy outcome (postpartum hemorrhage) in a medical record increases the likelihood that recurrence of the same event is reported in hospital data. Using a sample of 588 pregnancies [2 consecutive pregnancies for 294 randomly selected women with at least one postpartum hemorrhage (PPH)], we compared 'coded' recurrence rates in hospital data with those obtained from medical record audit. 'Coded' recurrence in a second pregnancy was also compared for women with or without a documented history of prior PPH. We found a 'coded' recurrence rate of 18.5% and an 'audited' recurrence rate of 28.4%. The 'coded' rate of recurrence among women who had a documented history of PPH was 27.4% compared to 19.1% when the previous PPH was not noted in the second pregnancy medical record. Medical record reporting of uterine atony as the cause for postpartum hemorrhages in first and second births was 37.9 and 34.0% while 'coded' hospital data reporting attributed 79.8 and 73.9% respectively to atony. Our study results indicate that a history of postpartum hemorrhage may be a stronger risk factor for subsequent PPH than previously demonstrated. A recorded history of PPH was associated with an increased likelihood of reporting a subsequent PPH, and in such cases recurrence rates approximate true recurrence. The contribution of uterine atony as a cause of postpartum hemorrhage is over-estimated using hospital data.

Trends and recurrence of placenta praevia: a population-based study.

We determined recent trends and recurrence rates of placenta praevia in 790,366 deliveries in NSW. From 2001 to 2009, the rate of placenta praevia increased by 26%, from 0. 69% to 0. 87% (trend P < 0.001). The placenta praevia recurrence rate in a second birth was 4.8%. Two-thirds of the increase in placenta praevia was accounted for by trends in known risk factors, and the unexplained portion may reflect changes in unidentified risk factors or in the threshold for placenta praevia diagnosis.

Pregnancy exposures and risk of childhood asthma admission in a population birth cohort.

BACKGROUND: There is increasing interest in the potential for in utero exposures to affect the risk of asthma. We used population data to explore the associations between perinatal conditions and the risk of hospital admission with asthma between the 2nd and 5th birthday. METHODS: The study population was 240,511 singleton infants born during 2001-2003. Birth records and longitudinally linked hospital admissions were used to identify asthma admissions and to model potential risk factors. RESULTS: A total of 7245 children (3.0%) had one or more childhood admissions with asthma. In utero infectious exposures associated with childhood asthma were maternal antenatal admission with a urinary tract infection (UTI) [adjusted odds ratio (aOR) = 1.49, 95% confidence interval (1.23-1.79)] and pre-term pre-labor rupture of membranes (PROM) [aOR = 1.23 (1.04-1.45)]. There was no evidence that gestational age at time of first antenatal UTI admission (<28, ≥ 28 wks) affected the risk of asthma (homogeneity test p = 0.6). Pre-term birth was a risk factor for asthma admission, with the risk decreasing by 5.3% with each extra week of gestation. Autumn and winter conceptions were associated with an increased risk of childhood asthma admission: winter aOR = 1.15 (1.08-1.23), autumn aOR = 1.09 (1.02-1.16). CONCLUSIONS: As in utero exposure to both UTI and PROM carry an increased risk of childhood asthma admission, this suggests that the immune system response generally is the relevant factor rather than a specific organism. The season-associated risk is consistent with early pregnancy exposures such as the winter flu season or low vitamin D.

Trends in use of neonatal CPAP: a population-based study.

BACKGROUND: Continuous positive airway pressure (CPAP) is used widely to provide respiratory support for neonates, and is often the first treatment choice in tertiary centres. Recent trials have demonstrated that CPAP reduces need for intubation and ventilation for infants born at 25-28 weeks gestation, and at > 32 weeks, in non-tertiary hospitals, CPAP reduces need for transfer to NICU. The aim of this study was to examine recent population trends in the use of neonatal continuous positive airway pressure. METHODS: We undertook a population-based cohort study of all 696,816 liveborn neonates ≥24 weeks gestation in New South Wales (NSW) Australia, 2001-2008. Data were obtained from linked birth and hospitalizations records, including neonatal transfers. The primary outcome was CPAP without mechanical ventilation (via endotracheal intubation) between birth and discharge from the hospital system. Analyses were stratified by age ≤32 and > 32 weeks gestation. RESULTS: Neonates receiving any ventilatory support increased from 1,480 (17.9/1000) in 2001 to 2,486 (26.9/1000) in 2008, including 461 (5.6/1000) to 1,465 (15.8/1000) neonates who received CPAP alone. There was a concurrent decrease in mechanical ventilation use from 12.3 to 11.0/1000. The increase in CPAP use was greater among neonates > 32 weeks (from 3.2 to 11.8/1000) compared with neonates ≤32 weeks (from 18.1 to 32.7/1000). The proportion of CPAP > 32 weeks initiated in non-tertiary hospitals increased from 6% to 30%. CONCLUSIONS: The use of neonatal CPAP is increasing, especially > 32 weeks gestation and among non-tertiary hospitals. Recommendations are required regarding which infants should be considered for CPAP, resources necessary for a unit to offer CPAP and monitoring of longer term outcomes.

Seasonal variation in pregnancy hypertension is correlated with sunlight intensity.

OBJECTIVE: To examine seasonality of pregnancy hypertension rates, and whether they related to sunlight levels around conception. STUDY DESIGN: Data were obtained for 424,732 singleton pregnancies conceived from 2001 through 2005 in Australia. We analyzed monthly rates of pregnancy hypertension and preeclampsia in relation to monthly solar radiation. RESULTS: Pregnancy hypertension rates, by month of conception, were lowest in autumn (7.3%) and highest in spring (8.9%). Higher sunlight intensity before delivery, but not around conception, was associated with decreased pregnancy hypertension (r = -0.67). Increased sunlight around conception may correlate with decreased rates of early-onset preeclampsia (r = -0.51; P = .09). CONCLUSION: The correlation between sunlight after conception and pregnancy hypertension was opposite to that hypothesized; however, sunlight levels before delivery did correlate with lower hypertension rates. For sunlight or ambient temperature to explain seasonal variation, the plausible exposure window is the period before delivery, but this may not apply to early-onset preeclampsia.

Regional block versus general anaesthesia for caesarean section and neonatal outcomes: a population-based study.

BACKGROUND: Anaesthesia guidelines recommend regional anaesthesia for most caesarean sections due to the risk of failed intubation and aspiration with general anaesthesia. However, general anaesthesia is considered to be safe for the foetus, based on limited evidence, and is still used for caesarean sections. METHODS: Cohorts of caesarean sections by indication (that is, planned repeat caesarean section, failure to progress, foetal distress) were selected from the period 1998 to 2004 (N = 50,806). Deliveries performed under general anaesthesia were compared with those performed under spinal or epidural, for the outcomes of neonatal intubation and 5-minute Apgar (Apgar5) <7. RESULTS: The risk of adverse outcomes was increased for caesarean sections under general anaesthesia for all three indications and across all levels of hospital. The relative risks were largest for low-risk planned repeat caesarean deliveries: resuscitation with intubation relative risk was 12.8 (95% confidence interval 7.6, 21.7), and Apgar5 <7 relative risk was 13.4 (95% confidence interval 9.2, 19.4). The largest absolute increase in risk was for unplanned caesareans due to foetal distress: there were five extra intubations per 100 deliveries and six extra Apgar5 <7 per 100 deliveries. CONCLUSION: The infants most affected by general anaesthesia were those already compromised in utero, as evidenced by foetal distress. The increased rate of adverse neonatal outcomes should be weighed up when general anaesthesia is under consideration.