Type of delivery onset has a significant impact on post-natal mortality in preterm infants of less than 30 weeks' gestation.

AIM: Type of delivery onset is not currently evaluated for its predictive impact. This study explored whether the type of preterm delivery onset was an antenatal predictor for post-natal mortality in preterm infants <30 weeks' gestation and should be included in antenatal counselling. METHODS: This retrospective cohort study included 1117 preterm infants <30 weeks' gestation born between 1999 and 2008 in a tertiary perinatal referral centre. Study patients were classified into spontaneous or iatrogenic preterm deliveries. Spontaneous deliveries included deliveries after preterm premature rupture of membranes (PPROM) and preterm labour. The study outcome was infant mortality before discharge from hospital. RESULTS: We included 499 patients born after PPROM (44.7%) and 247 born after preterm labour (22.1%). Iatrogenic preterm birth was noted in 282 patients (25.2%) and 89 patients fulfilled both criteria for spontaneous and iatrogenic preterm delivery (8.0%). Babies born after iatrogenic preterm delivery in gestational weeks 25-29 had significantly higher mortality rates. Logistic regression revealed that type of preterm delivery onset was an independent antenatal predictor for post-natal mortality. CONCLUSION: Type of preterm delivery onset had a significant impact on post-natal mortality in preterm infants <30 weeks' gestation, with a higher mortality rate after iatrogenic preterm delivery.

[Antibiotics in pregnancy]. / Antibiotika in der Schwangerschaft.

There are clear indications for antibiotic therapy in pregnancy and antibiotics are commonly prescribed in pregnancy. Potential fetal and maternal side-effects are known for several antibiotic substances, but not for all. In this article, the safety of the most common antibiotic substances will be reviewed, and potential risks are described in detail. Even though several antibiotics are contraindicated in pregnancy, a good choice of safe substances will be available for most indications.

Adjunctive antibiotic treatment in preterm labor and neonatal morbidity: a meta-analysis.

OBJECTIVE: To estimate the effect of prophylactic antibiotics on neonatal mortality and morbidity in patients with preterm labor, based on a meta-analysis of seven published randomized clinical trials. DATA SOURCES: We searched 18 medical data bases, including MEDLINE from 1964 and EMBASE from 1974, to identify all literature included under preterm or premature labor and antibiotics. We scanned all abstracts from the computer printouts, the retrieved full-text reports, the references from each retrieved report, and review articles to determine whether studies met our inclusion criteria. METHODS OF STUDY SELECTION: The following criteria were used to select studies for inclusion: article-original published report written in English; study design-randomized controlled trial; population-patients with preterm labor, defined as labor before 37 weeks' gestation; intervention-antibiotic treatment; and one or more of the following outcomes-neonatal mortality, sepsis, pneumonia, respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. TABULATION, INTEGRATION AND RESULTS: We analyzed study patients and methods, and abstracted quantitative outcome data. For each outcome, both odds ratio (OR) and 95% confidence interval (CI) were calculated. Seven trials, published between 1989 and 1995 included a total of 795 patients. Adjunctive antibiotic therapy appeared to reduce the risk of pneumonia (OR 0.45, 95% CI 0.12-1.72) and necrotizing enterocolitis (OR 0.38, 95% CI 0.14-1.08) and to increase the risk of neonatal mortality (OR 3.25, 95% CI 0.93-11.38), but it had no effect on neonatal sepsis (OR 0.98, 95% CI 0.34-2.83), respiratory distress syndrome (OR 0.93, 95% CI 0.54-1.87), and intraventricular hemorrhage (OR 1.01, 95% CI 0.20-5.10). None of the effects observed reached a significance level of P < .05. CONCLUSION: The results of this meta-analysis do not support the routine use of adjunctive antibiotic treatment in patients with preterm labor diagnosed on the basis of subjective uterine contractions and the resulting cervical changes.

The passage of granulocyte-macrophage colony-stimulating factor across the human placenta perfused in vitro.

OBJECTIVE: The purpose of this study was to investigate the placental passage of granulocyte-macrophage colony-stimulating factor in a placental perfusion model ex vivo. METHODS: In an open system, 11 placentas were perfused on both the maternal and the fetal side immediately after delivery. Granulocyte-macrophage colony-stimulating factor was added to the maternal perfusion medium in concentrations from 10-55 micrograms/mL. Maternal and fetal samples were taken, and granulocyte-macrophage colony-stimulating factor (GM-CSF) was measured by enzyme-linked immunosorbent assay. RESULTS: Accumulation of granulocyte-macrophage colony-stimulating factor in the fetal circuit averaged 2.42% of the concentration added initially to the arterial portion of the maternal circuit. CONCLUSION: There is only low transfer of GM-CSF across the fetal membranes. This finding is particularly remarkable in view of recently published results suggesting that administration of recombinant granulocyte growth factors to pregnant women with imminent preterm delivery helps prevent neonatal sepsis.

Contraceptive knowledge and attitudes of Austrian adolescents after mass media reports linking third-generation oral contraceptives with an increased risk of venous thromboembolism.

We performed a representative survey to determine the level of knowledge of 1,010 Austrian adolescents aged 14 to 24 years about selected facts relating to the recent massive news coverage of the increase in the risk of venous thromboembolism in users of third-generation oral contraceptives and to assess the contraceptive behavior of this population. The overall use rate of oral contraceptives and condoms had increased significantly between 1991 and 1996. Sixty-six percent of the adolescents surveyed stated not having heard or read any media reports on oral contraceptives. Only 8% of those who had knew that most reports focused on the pill as a possible cause of venous thromboembolism, whereas the majority of respondents indicated that the media conveyed doubts regarding the health safety of oral contraceptives in general. Nearly half of adolescents were unable to define what a thrombosis was. Thus, although the mass media play an important role in transmitting medical information, the dissemination of practical, accurate advice on the risks of a drug and competent patient counseling is reserved for the health care professionals.

Direct visual or blind insertion of the primary trocar.

BACKGROUND: We set out to assess the difference in complication rates between primary umbilical insertion by a blind trocar and insertion with an optical surgical obturator. METHODS: In a retrospective survey, we investigated the rate of severe complications by primary umbilical trocar entry. Of 1546 patients undergoing gynecological laparoscopies at a tertiary-care university hospital, 1000 cases were operated by blind umbilical insertion with a conventional primary trocar whereas 546 used an optical primary trocar. RESULTS: The rate of major complications during insertion of the primary trocar in the blind insertion group was five of 1000 (0.5%), whereas there were no major complications in the optical-guided insertion group (0.0%). CONCLUSIONS: In comparison with the blind insertion of a sharp trocar, optical guidance provides a safe and functional primary insertion method that allows to detect adhesions to be detected at an early stage, thus preventing injuries to the bowel and abdominal vessels.

Development and evaluation of fuzzy criteria for the diagnosis of rheumatoid arthritis.

In 1987, the American Rheumatism Association issued a set of criteria for the classification of rheumatoid arthritis (RA) to provide a uniform definition of RA patients. Fuzzy set theory and fuzzy logic were used to transform this set of criteria into a diagnostic tool that offers diagnoses at different levels of confidence: a definite level, which was consistent with the original criteria definition, as well as several possible and superdefinite levels. Two fuzzy models and a reference model which provided results at a definite level only were applied to 292 clinical cases from a hospital for rheumatic diseases. At the definite level, all models yielded a sensitivity rate of 72.6% and a specificity rate of 87.0%. Sensitivity and specificity rates at the possible levels ranged from 73.3% to 85.6% and from 83.6% to 87.0%. At the superdefinite levels, sensitivity rates ranged from 39.0% to 63.7% and specificity rates from 90.4% to 95.2%. Fuzzy techniques were helpful to add flexibility to preexisting diagnostic criteria in order to obtain diagnoses at the desired level of confidence.

A prospective evaluation of the medical consultation system CADIAG-II/RHEUMA in a rheumatological outpatient clinic.

To evaluate the performance of CADIAG-II/RHEUMA as consultant in the primary evaluation of patients visiting a rheumatological outpatient clinic, a CADIAG-II/RHEUMA consultation was done for 54 patients and the list of generated diagnostic hypotheses was compared to each clinical discharge diagnosis. For 26 of a total of 126 rheumatological discharge diagnoses, no matching CADIAG-II/RHEUMA diagnosis was available. 94% of all other discharge diagnoses were found in the list of CADIAG-II/RHEUMA hypotheses, 82% among the first third of the list of hypotheses and 48% among the first five hypotheses. We identified the following factors limiting the ability of CADIAG-II/RHEUMA to generate a comprehensive and correctly ranked list of diagnostic hypotheses: (1) a large percentage of patients with early stages of not clearly identified rheumatological conditions; (2) the limited number of CADIAG-II/RHEUMA diagnoses compared to the large number of known rheumatological conditions; (3) the fact that rheumatological diseases are rarely characterized by a single pathognomonic feature but are usually diagnosed by combinations of rather unspecific findings.

SIDS related anxiety--a risk factor analysis.

BACKGROUND: The growing public interest in the Sudden Infant Death Syndrome (SIDS) has led to a new psychological problem--SIDS related anxiety (SRA). General public awareness, unfavourable experience in the past, present problems with the infant or insufficient support from the family may lead or contribute to SRA. OBJECTIVE: The study was conducted to explore which of these factors contribute most to the development of SRA. PATIENTS AND METHODS: Families visiting our outpatient clinic during 18 months were interviewed by means of a structured questionnaire. We assessed demographic data, obstetric history, experience of child loss, pregnancy and delivery complications, infant morbidity, family-child interaction, family support and the relation of each of these single factors to SRA. RESULTS: Of 169 families, 58% (98/169) admitted to suffer from SRA and 21% (32/156) from severe SRA. We found a strong and significant relationship between previous experience of child loss and SRA (OR: 2.95, 95% CI: 1.43-6.09, P < 0.005) and between pregnancy complications and SRA (OR: 2.19, 95% CI: 1.18-4.08, P < 0.05). There were no significant relationships between SRA and either delivery complications, child morbidity, impaired family-child interaction or insufficient support from the family. CONCLUSIONS: SRA occurs in an unexpectedly large proportion of families visiting a SIDS counseling clinic. SRA must be taken seriously, and psychological or psychotherapeutic help should be offered. Prevention of SRA should include psychological care for families who experience loss of children or high-risk pregnancies.

Is it possible to make a reliable prognosis within the first hour of life for very low birth weight infants delivered after preterm premature rupture of membranes?

BACKGROUND: One third of all preterm births are due to preterm premature rupture of membranes (pPROM). An accurate prognostic evaluation after admission to the neonatal intensive care unit is necessary. OBJECTIVE: The aim of this study was to identify prognostic factors within the first hour of life for mortality, short-term pulmonary morbidity, chronic lung disease (CLD) and severe cerebral morbidity in very low birth weight (VLBW) infants after pPROM. METHODS: This retrospective study included 300 infants with pPROM who fit the study criteria and were derived from a cohort of 1,435 VLBW infants. A total of 17 obstetric and neonatal factors were evaluated by univariate and multivariate analysis. RESULTS: Gestational age at birth and 5-min Apgar score correlated significantly with all 4 outcomes. The results of the first blood gas analysis correlated with 3 outcomes and the first mean arterial pressure with 2 outcomes. Anhydramnios and a lower number of courses of antenatal steroids correlated with higher mortality, and preterm labor correlated with CLD. The multivariate analysis revealed gestational age, 5-min Apgar score, the results of the first blood gas analysis, the first mean arterial pressure and anhydramnios to be significant predictors. The positive predictive value ranged from 20 to 81%, and the negative predictive value ranged from 79 to 92%. CONCLUSION: Gestational age at birth and parameters reflecting postnatal adaptation were the most precise factors for assessment of the prognosis of VLBW infants after pPROM within the first hour of life. Apart from anhydramnios, obstetric factors did not predict neonatal outcome. At 1 h of age, our models of perinatal risk factors were more effective in predicting a favorable outcome than an adverse outcome.

Perinatal outcome of preterm infants <1500 g after IVF pregnancies compared with natural conception.

OBJECTIVE: In vitro fertilisation (IVF) pregnancies are at increased risk for adverse perinatal outcome including very low birth weight infants. The purpose of this study was to find out whether the perinatal outcome of preterm infants <1500 g after IVF is different from those in naturally conceived pregnancies. PATIENTS AND METHODS: This retrospective cohort study included preterm infants <1500 g born between 1999 and 2007 in a tertiary perinatal referral centre. All analyses were made separately for singletons and multiples, divided into infants <1000 g and 1000-1499 g. The primary study outcomes were infant mortality, short term pulmonary morbidity and cerebral morbidity. The secondary study outcomes were small for gestational age, Apgar score at 5 min, the results of the first venous blood gas analysis of the preterm infant, and the first mean arterial blood pressure after neonatal intensive care unit admission. Logistic regression analysis was done to assess the impact of IVF compared to other maternal and infant factors. RESULTS: 1423 patients (195 IVF and 1228 non-IVF patients) were included in this study. The incidence of preterm labour was significantly higher in multiples after IVF than in spontaneously conceived multiples. In the IVF group, there were significantly more multiples. Mortality, pulmonary morbidity and cerebral morbidity did not differ among patients after IVF and naturally conceived patients. Also, there were no significant differences for the secondary outcomes, except for a significantly higher initial pH value in multiples after IVF between 1000-1499 g. CONCLUSION: IVF treatment was not associated with adverse outcome in very low birth weight infants. IVF, preterm birth, VLBW, singletons, multiples, outcome.

Antipsychotic drugs and dopamine-stimulated adenylate cyclase prepared from corpus striatum of rat brain.

Antipsychotic drugs and their clinically impotent congeners were examined as inhibitors of dopamine-sensitive adenylate cyclase (EC 4.6.1.1) in cell-free membrane preparations of the caudate-putamen of rat brain. Of 12 neuroleptic drugs with reported antipsychotic efficacy, all inhibit stimulation of adenylate cyclase by 40 muM dopamine at micromolar concentrations. Among 14 other structurally related drugs that are not clinically effective as antipsychotic agents, 12 were almost ineffective while two drugs were moderate inhibitors of dopamine-sensitive adenylate cyclase.

A meta-analysis of low dose aspirin for the prevention of intrauterine growth retardation.

OBJECTIVE: To determine more precisely the effect of prophylactic low dose aspirin on intrauterine growth retardation and perinatal mortality. DESIGN: Meta-analysis of 13 published randomised clinical trials. METHODS: We searched 18 medical databases, including MEDLINE since 1964 and EMBASE since 1974, review articles and the references from each retrieved report to identify all studies evaluating the effect of aspirin in pregnancy and including both intrauterine growth retardation and perinatal mortality as outcome measures. RESULTS: Among 13,234 women from 13 studies between 1985 and 1994, aspirin showed a significant reduction in intrauterine growth retardation (IUGR) (OR 0.82; 95% CI 0.72-0.93; P = 0.003) and a nonsignificant reduction in perinatal mortality (OR 0.84; 95% CI 0.66-1.08; P = 0.18). Subgroup analyses revealed that aspirin was effective at lower doses between 50 and 80 mg/day (IUGR: OR 0.87; 95% CI 0.76-0.99; mortality: OR 0.90, 95% CI 0.70-1.16), but that the preventive effect was greater at higher doses between 100 and 150 mg/day (IUGR: OR 0.36, 95% CI 0.22-0.59; mortality: OR 0.40, 95% CI 0.16-0.97) and among women entered before the 17th week of gestation (IUGR: OR 0.35, 95% CI 0.21-0.58; mortality: OR 0.43, 95% CI 0.17-1.06). We did not identify any specific subgroup of women most likely to benefit from aspirin treatment. CONCLUSION: The results of this meta-analysis showed that early aspirin treatment reduced the risk of intrauterine growth retardation. Low dose aspirin should not be used routinely in pregnant women until those most likely to benefit from aspirin treatment have been clearly identified.

Fetal fibronectin as a predictor of term labor: a literature review.

OBJECTIVE: Accurately predicting the onset of delivery continues to be problematic notwithstanding the clinical relevance of this capability, especially with regard to the elective induction of labor. While the assessment of the cervix according to Bishop, to date, constitutes the single generally recognized method, the determination of fetal fibronectin (FFN) cervicovaginal secretions promises greater precision in this context. DESIGN: English-language medical literature was analyzed using the search parameter 'fetal fibronectin', 'term delivery', 'induction of labor', 'labor', and 'birth', respectively. All those original reports examining cervicovaginal FFN that were originally published in English and followed a prospective design were subsequently included in the study at hand. These reports were evaluated in regard to their findings on the predictive value of FFN for spontaneous delivery and induction of labor. RESULTS: A total of eight reports were included in the present study: five of these, covering a total of 480 patients, discussed the relationship between FFN and the spontaneous onset of labor; the other three addressed the subject of FFN and the induction of labor (300 patients). All reports clearly related the presence of FFN in cervicovaginal secretions to the imminent onset of delivery; three studies, furthermore, demonstrated a correlation with the spontaneous onset of labor, with a sensitivity greater than 90%. In case of the studies concerning induction of labor, a positive FFN result was accompanied by a significantly shorter interval until delivery than a negative FFN result. CONCLUSION: Determining the presence of FFN in cervicovaginal secretions promises to provide an indicator relating to the prediction of term labor, as well as to the prediction of successful labor induction.

Antibiotic treatment in preterm premature rupture of membranes and neonatal morbidity: a metaanalysis.

OBJECTIVE: We performed a metaanalysis of seven published randomized clinical trials to estimate more precisely the effect of prophylactic antibiotics on neonatal mortality, clinical sepsis of the neonate, respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. STUDY DESIGN: To evaluate the effect of antibiotic treatment unaffected by other forms of treatment such as tocolytics or corticosteroids, investigations in which these additional measures were used were not included. We analyzed study patients and methods and abstracted quantitative outcome data. For each outcome both odds ratios and 95% confidence intervals were calculated. RESULTS: Among the 657 patients from seven trials published between 1989 and 1994, antibiotic therapy significantly reduced the risk of neonatal sepsis by 68% (odds ratio 0.32, 95% confidence interval 0.16 to 0.65, p=0.001) and that of intraventricular hemorrhage by 50% (odds ratio 0.50, 95% confidence interval 0.28 to 0.89, p=0.019). In contrast, no significant effect of antibiotics on overall neonatal mortality (odds ratio 0.92, 95% confidence interval 0.46 to 1.81), respiratory distress syndrome (odds ratio 0.84, 95% confidence interval 0.58 to 1.22), or necrotizing enterocolitis (odds ratio 1.27, 95% confidence interval 0.61 to 2.62) was found. CONCLUSION: This metaanalysis supports an improvement of neonatal morbidity in mothers with preterm premature rupture of membranes treated prenatally with different antibiotic regimens.

Cervical length and dilatation of the internal cervical os detected by vaginal ultrasonography as markers for preterm delivery: A systematic review.

OBJECTIVE: We performed a systematic review to evaluate endovaginal cervical ultrasonography as a predictor of preterm delivery. STUDY DESIGN: Selection criteria were original published English-language reports of prospective studies including women at <37 weeks' gestation with intact amniotic membranes. Parameters and outcomes were cervical length or dilatation of the internal cervical os and preterm delivery. RESULTS: In 3 subgroups of studies including patients with preterm labor or low-risk, symptom-free patients with early (20-24 weeks) or late (27-32 weeks) ultrasonographic examination, optimal cutoff values for cervical lengths ranged between 18 and 30, 25 and 35, or 25 and 39 mm. At these cutoff values, sensitivity rates were between 68% and 100%, 33% and 54%, or 63% and 76%, and specificity rates were between 44% and 79%, 73% and 91%, or 59% and 69%, respectively. Sensitivity rates for dilatation of the internal cervical os were 70% to 100%, 16% to 25%, or 33%, and specificity rates were 54% to 75%, 95% to 99%, or 92%, respectively. CONCLUSION: In patients with symptoms of preterm labor, endovaginal cervical ultrasonography appears to be an effective predictor of preterm delivery.

Cervicovaginal fetal fibronectin as a marker for preterm delivery: a meta-analysis.

OBJECTIVE: We performed a meta-analysis to determine the value of cervicovaginal fetal fibronectin as a marker for preterm delivery. STUDY DESIGN: Selection criteria confined the analysis to original, English-language reports of prospective studies including women at <37 weeks' gestation with intact amniotic membranes. For the outcomes of delivery at <37 or <34 weeks' gestation or delivery within 7, 14, 21, or 28 days after fibronectin sampling, we calculated sensitivity and specificity rates for each study, for subgroups of studies, and for all studies combined. RESULTS: A total of 27 studies met our inclusion criteria. For the outcomes of delivery at <37 and <34 weeks' gestation, overall sensitivity rates were 56% and 61% and overall specificity rates were 84% and 83%, respectively. For the outcomes of delivery within 7, 14, 21, and 28 days, we calculated sensitivity rates of 76%, 68%, 61%, and 43% and specificity rates of 88%, 89%, 91%, and 93%, respectively. For the subgroup of patients with symptoms of preterm labor, sensitivity rates for delivery within 7, 14, 21, and 28 days of 89%, 78%, 76%, and 71% and specificity rates of 86%, 86%, 88%, and 83%, respectively, were calculated. CONCLUSION: Among patients with symptoms of preterm labor, cervicovaginal fetal fibronectin appears to be among the most effective predictors of preterm delivery.

Concomitant use of glucocorticoids: a comparison of two metaanalyses on antibiotic treatment in preterm premature rupture of membranes.

OBJECTIVE: This study was performed to investigate whether the demonstrated beneficial effects of antibiotics on maternal and neonatal morbidity are altered when glucocorticoids are part of the treatment of preterm premature rupture of membranes. STUDY DESIGN: We performed a metaanalysis of five published, randomized trials of antibiotic treatment in preterm premature rupture of membranes in which glucocorticoids were used as additional treatments and compared the results with those of a previously published metaanalysis of antibiotic treatment in preterm premature rupture of membranes, which excluded studies with concomitant glucocorticoids. Primary outcomes included chorioamnionitis, postpartum endometritis, neonatal sepsis, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and neonatal mortality. A logistic regression analysis was performed to test whether glucocorticoids significantly influenced the effect of antibiotic treatment. RESULTS: Among the 509 patients from five trials on antibiotic and glucocorticoid treatment published between 1986 and 1993 antibiotic therapy did not show any significant effect on any of the outcomes analyzed. In contrast, antibiotic therapy without concomitant use of glucocorticoids significantly reduced the odds of chorioamnionitis, postpartum endometritis, neonatal sepsis, and intraventricular hemorrhage by 62%, 50%, 68%, and 50%, respectively. The logistic regression analysis showed that glucocorticoids significantly diminished the effect of antibiotic treatment on chorioamnionitis and neonatal sepsis. CONCLUSION: Glucocorticoids appear to diminish the beneficial effects of antibiotics in the treatment of preterm premature rupture of membranes. A careful selection of patients who are likely to benefit from both therapies is therefore recommended.