Suboptimal factors in maternal and newborn care for refugees: Lessons learned from perinatal audits in the Netherlands.

INTRODUCTION: Refugees and their healthcare providers face numerous challenges in receiving and providing maternal and newborn care. Research exploring how these challenges are related to adverse perinatal and maternal outcomes is scarce. Therefore, this study aims to identify suboptimal factors in maternal and newborn care for asylum-seeking and refugee women and assess to what extent these factors may contribute to adverse pregnancy outcomes in the Netherlands. METHODS: We conducted a retrospective analysis of national perinatal audit data from 2017 to 2019. Our analysis encompassed cases with adverse perinatal and maternal outcomes in women with a refugee background (n = 53). Suboptimal factors in care were identified and categorized according to Binder et al.'s Three Delays Model, and the extent to which they contributed to the adverse outcome was evaluated. RESULTS: We identified 29 suboptimal factors, of which seven were related to care-seeking, six to the accessibility of services, and 16 to the quality of care. All 53 cases contained suboptimal factors, and in 67.9% of cases, at least one of these factors most likely or probably contributed to the adverse perinatal or maternal outcome. CONCLUSION: The number of suboptimal factors identified in this study and the extent to which they contributed to adverse perinatal and maternal outcomes among refugee women is alarming. The wide range of suboptimal factors identified provides considerable scope for improvement of maternal and newborn care for refugee populations. These findings also highlight the importance of including refugee women in perinatal audits as it is essential for healthcare providers to better understand the factors associated with adverse outcomes to improve the quality of care. Adjustments to improve care for refugees could include culturally sensitive education for healthcare providers, increased workforce diversity, minimizing the relocation of asylum seekers, and permanent reimbursement of professional interpreter costs.

Central-line-associated bloodstream infection burden among Dutch neonatal intensive care units.

BACKGROUND: The establishment of an epidemiological overview provides valuable insights needed for the (future) dissemination of infection-prevention initiatives. AIM: To describe the nationwide epidemiology of central-line-associated bloodstream infections (CLABSI) among Dutch Neonatal Intensive Care Units (NICUs). METHODS: Data from 2935 neonates born at <32 weeks' gestation and/or with a birth weight <1500 g admitted to all nine Dutch NICUs over a two-year surveillance period (2019-2020) were analysed. Variations in baseline characteristics, CLABSI incidence per 1000 central-line days, pathogen distribution and CLABSI care bundles were evaluated. Multi-variable logistic mixed-modelling was used to identify significant predictors for CLABSI. RESULTS: A total of 1699 (58%) neonates received a central line, in which 160 CLABSI episodes were recorded. Coagulase-negative staphylococci were the most common infecting organisms of all CLABSI episodes (N=100, 63%). An almost six-fold difference in the CLABSI incidence between participating units was found (2.91-16.14 per 1000 line-days). Logistic mixed-modelling revealed longer central line dwell-time (adjusted odds ratio (aOR):1.08, P<0.001), umbilical lines (aOR:1.85, P=0.03) and single rooms (aOR:3.63, P=0.02) to be significant predictors of CLABSI. Variations in bundle elements included intravenous tubing care and antibiotic prophylaxis. CONCLUSIONS: CLABSI remains a common problem in preterm infants in The Netherlands, with substantial variation in incidence between centres. Being the largest collection of data on the burden of neonatal CLABSI in The Netherlands, this epidemiological overview provides a solid foundation for the development of a collaborative platform for continuous surveillance, ideally leading to refinement of national evidence-based guidelines. Future efforts should focus on ensuring availability and extraction of routine patient data in aggregated formats.

[Neonatal infection with Listeria monocytogenes: rare, but serious]. / Neonatale infectie met listeria monocytogenes: zeldzaam, maar ernstig.

Between 1993 and 2003, three infants, two girls and a boy, were found to have an invasive infection with Listeria monocytogenes. They received intensive care including respiratory and circulatory support, antibiotics, and treatment of the neurological complications when possible. One of the girls survived without sequelae but the other two infants died in the neonatal period. In one of these two cases there was a clear clue to the source of the infection in the dietary history of the mother: she had consumed unpasteurised cow's milk. The mothers ofthe infants that died had developed fever shortly before parturition. In The Netherlands, the incidence of neonatal invasive infection with Listeria is estimated at 1.3 per 100,000 live-born children per year. This figure seems not to have changed in the last 20 years. Because of the risk of this rare but serious infection, dietary advice to pregnant women to avoid possibly contaminated food is still relevant.

[Primary cytomegalovirus infection in the postnatal period]. / Primaire cytomegalovirus-infectie in de postnatale periode.

A male infant born vaginally after a gestation period of 25 4/7 weeks with a birth weight of 875 g underwent surgical correction for oesophageal atresia with a distal tracheo-oesophageal fistula. Postoperative complications included seam leakage, mediastinitis with sepsis, transient elevated diaphragm, recurrent fistula and seam stenosis. Persistent ductus arteriosus was closed surgically. The further course of disease was characterised by periventricular haemorrhage, recurrent infections, bronchopulmonary dysplasia and retinopathy. Anaemia caused by the premature birth and frequent blood sampling necessitated multiple transfusions of filtered, Cytomegalovirus(CMV)-free erythrocyte concentrate. At the age of 3 months, the patient developed cholestatic jaundice that was attributed to a CMV infection contracted through breast milk. The patient recovered spontaneously. At the age of 2 years, the patient had mildly impaired psychomotor development. Reactivation of CMV during lactation is common in CMV-seropositive women. This carries a high risk of transmission of the virus through breast milk, especially for extremely premature neonates. In these infants, an early acquired postnatal CMV infection may lead to serious disorders.

Referral and transportation for neonatal extracorporeal membrane oxygenation.

Data from 32 patients who were transported for neonatal extracorporeal membrane oxygenation (ECMO) over a 66-month period were reviewed. One ground ambulance transport had to be postponed because of poor weather conditions; the patient died. One patient was excluded for ECMO on arrival at the ECMO centre. Of the remaining 30 infants, 20 (67%) required ECMO treatment, of which four (20%) died. All 10 (33%) patients who were treated with conventional therapy survived. During transportation all children remained stable in terms of oxygenation. Early referral and transportation by an experienced and well-equipped transport team allows safe transport of these critically ill neonates.

[Bilirubin encephalopathy in an icteric bile-vomiting infant with high intestinal obstruction]. / Bilirubine-encefalopathie bij een icterische, 'gallig' spugende zuigeling met hogedarmobstructie.

In a 5-day-old full-term, dehydrated boy with bilious vomiting and a cephalhaematoma, bilirubin encephalopathy was diagnosed at a serum bilirubin level of 395 mumol/l. The patient was rehydrated intravenously and treated with phototherapy and an exchange transfusion, after which the serum bilirubin level decreased. The neurological condition normalised during his stay in the hospital. Hyperbilirubinaemia was caused by an increased enterohepatic circulation due to a high intestinal obstruction and resorption of the cephalhaematoma. Toxicity was caused by dehydration and fasting. Even with new bilirubin guidelines it remains important to distinguish a healthy neonate from an ill jaundiced neonate, because at lower serum bilirubin levels symptoms may occur that fit the clinical picture of a bilirubin encephalopathy.

[Diagnostic image (121). An artificially ventilated neonate with abdominal distension. Pneumoperitonium secondary to intrathoracic air leakage]. / Diagnose in beeld (121). Een beademde neonatus met een bolle buik. Pneumoperitoneum door intrathoracale luchtlekkage.

A male neonate was artificially ventilated because of respiratory insufficiency. He developed a pneumoperitoneum secondary to pulmonary air leakage.

[Diagnostic image (143). A neonate with a skin disorder. Congenital cutaneous candidiasis]. / Diagnose in beeld (143). Een neonatus met een huidafwijking. Congenitale cutane candidiasis.

A premature neonate was born with a generalized eruption of vesicles, within a day developing into an erythrodermia, with bullae and widespread desquamation, due to congenital cutaneous candidiasis.

[Syndromes 16. Osteogenesis imperfecta]. / Syndromen 16. Osteogenesis imperfecta.

Osteogenesis imperfecta consists of a group of hereditary connective tissue diseases with fragility of the bone as a general feature. Frequently occurring other characteristics are blue sclerae, opalescent teeth, hearing loss, disorders of the skeleton, and hyperextensibility of the joints. Obliteration and the unusual shape of the pulp chambers may interfere with dental treatment.

Patient characteristics in persistent pulmonary hypertension of the newborn.

Objective. To assess the impact of PPHN on mortality, morbidity, and behavioural skills. Methods. A retrospective observational study of 143 newborns with PPHN, over an 11-year period, using objective health-status data from medical records and family doctors, and subjective health status data from a standardized Child Behaviour Checklist. Results. The majority of patients were males, treated with inhaled nitric oxide had maladaptation/maldevelopment as pathophysiological mechanism and a gestational age >37 weeks. In term newborns, types of pathophysiological mechanism (P < .001) and Oxygen Index (P = .02) were independent predicting risk factors for PPHN-related mortality. Analysis of preexisting disease and outcome categories in term newborns showed only a significant correlation between the use of iNO and respiratory complaints (P = .03), not confirmed by multivariate analysis and regression analysis. Conclusions. PPHN is a serious, often fatal condition. The incidence of PPHN in preterm newborns is high. In term survivors, PPHN had no additional role in morbidity/outcome.

Fatal illness associated with pulmonary hypertension in a neonate caused by intrauterine echovirus 11 infection.

Nonpolio enterovirus (NPEV) infections are known to cause a wide range of illnesses in the neonatal period. In most cases, NPEV is presumed to be contracted during birth. Intrauterine NPEV infections occur infrequently. A case of intrauterine echovirus 11 infection with pneumonia, persistent pulmonary hypertension of the newborn, and purpura fulminans is presented.

The Tulip classification of perinatal mortality: introduction and multidisciplinary inter-rater agreement.

OBJECTIVE: To introduce the pathophysiological Tulip classification system for underlying cause and mechanism of perinatal mortality based on clinical and pathological findings for the purpose of counselling and prevention. DESIGN: Descriptive. SETTING: Tertiary referral teaching hospital. POPULATION: Perinatally related deaths. METHODS: A classification consisting of groups of cause and mechanism of death was drawn up by a panel through the causal analysis of the events related to death. Individual classification of cause and mechanism was performed by assessors. Panel discussions were held for cases without consensus. MAIN OUTCOME MEASURES: Inter-rater agreement for cause and mechanism of death. RESULTS: The classification consists of six main causes with subclassifications: (1) congenital anomaly (chromosomal, syndrome and single- or multiple-organ system), (2) placenta (placental bed, placental pathology, umbilical cord complication and not otherwise specified [NOS]), (3) prematurity (preterm prelabour rupture of membranes, preterm labour, cervical dysfunction, iatrogenous and NOS), (4) infection (transplacental, ascending, neonatal and NOS), (5) other (fetal hydrops of unknown origin, maternal disease, trauma and out of the ordinary) and (6) unknown. Overall kappa coefficient for agreement for cause was 0.81 (95% CI 0.80-0.83). Six mechanisms were drawn up: cardio/circulatory insufficiency, multi-organ failure, respiratory insufficiency, cerebral insufficiency, placental insufficiency and unknown. Overall kappa for mechanism was 0.72 (95% CI 0.70-0.74). CONCLUSIONS: Classifying perinatal mortality to compare performance over time and between centres is useful and necessary. Interpretation of classifications demands consistency. The Tulip classification allows unambiguous classification of underlying cause and mechanism of perinatal mortality, gives a good inter-rater agreement, with a low percentage of unknown causes, and is easily applicable in a team of clinicians when guidelines are followed.

Acute renal failure in a neonate due to pelviureteric candidal bezoars successfully treated with long-term systemic fluconazole.

Systemic candidiasis with renal involvement is a rare but well-recognized complication during intensive care treatment in very-low-birth-weight infants. We report a term neonate who developed anuria associated with bilateral bezoar formation in the renal pelvis and candidemia. The treatment consisted of placement of a nephrostomy tube in the left kidney, short-term irrigation with amphotericin B and iv, and later, oral administration of fluconazole.

Fulminant neonatal sepsis due to Haemophilus influenzae.

A case of fulminant neonatal Haemophilus influenzae sepsis is presented. A 29-year-old woman presented at 34 weeks gestation with premature labor but with intact membranes. The male infant died 8 h after delivery due to respiratory insufficiency. Ante-mortem blood cultures and post-mortem blood and lung cultures yielded H. influenzae (biotype II) which could not be serotyped. H. influenzae was cultured from the mother's cervix 5 days after delivery. This strain was of the same biotype and also nonserotypable. Serum obtained from the mother exhibited reduced bactericidal activity against the isolates. We suggest the use of selective media in routine cervix cultures from pregnant women to detect H. influenzae, which might be responsible for neonatal septicemia.

[Fingerprinting with the polymerase chain reaction: confirmation of a Enterobacter cloacae epidemic in a neonatal intensive care unit]. / Fingerprinting mittels Polymerase-Kettenreaktion: Nachweis einer Enterobacter-cloacae-Epidemie auf einer neonatologischen Intensivstation.

Between end December 1993 and end January 1994 a cluster of children infected/colonized with Enterobacter cloacae was seen in the neonatal intensive care unit of the University Hospital Nijmegen. The results of the epidemiological investigation are reported, which was aimed to differentiate between a random cluster of endogenously acquired Enterobacter strains and those possibly acquired exogenously via cross-infection. 5 isolates of the 7 patients were available for fingerprinting using interrepeat PCR. According to the fingerprint pattern, 4 of these isolates were identical, thereby suggesting cross-infection among the children. 3 neonates were colonized/infected with genotypically different isolates, suggesting that the infection/colonization developed endogenously. A control strain isolated from a patient at another ward showed the same genotype as the outbreak isolates. The transmission took probably place through one of the surgeons who, among all possible health care workers, were the only professional group treating patients in both units.