Detection of postpartum uterine activity with electrohysterography.

OBJECTIVE: Uterine contractions are essential for childbirth, but also for expulsion of the placenta and for limiting postpartum blood loss. Postpartum hemorrhage is associated with almost 25% of the maternal deaths worldwide and the leading cause of maternal death in most low-income countries. Little is known about the physiology of the uterus postpartum, particularly due to the lack of an accurate measurement tool. The primary objective of this pilot study is to explore the potential of using electrohysterography to detect postpartum uterine contractions. If postpartum uterine activity can be objectified, this could contribute to understanding the physiology of the uterus and improve diagnosis and treatment of postpartum hemorrhage. STUDY DESIGN: In this observational study we included women aiming for a vaginal birth in two large maternity clinics in the Netherlands, Amphia Hospital Breda (group A, N2018-0161) and Máxima Medical Center Veldhoven (group B, N17.149). An electrode patch was placed on the maternal abdomen to record real-time electrical uterine activity until one hour postpartum continuously. In group A, the placement of the patch was lower than in group B. For analysis, tracings were divided into five different phases (1: dilatation until start pushing, 2: from start pushing until childbirth, 3: from childbirth until placental expulsion, 4: first hour after placental expulsion and 5: after one hour postpartum). Readability, signal quality and contraction frequency per hour were assessed. Additionally, patient satisfaction was evaluated through a survey. RESULTS: In total 91 pregnant women were included of whom 45 in group A and 46 women in group B. Complete registrations were obtained throughout the five labor phases with very little artefacts or signal loss. The readability of the tracings decreased after childbirth. A significantly better readability was found in tracings where the patch placement was lower on the abdomen for phases 4 and 5. Contraction frequency was highest during phase 2 and decreased towards phase 5. Women rated the satisfaction with electrohysterography as high and mostly did not notice the patch. CONCLUSION: It is possible to detect uterine activity postpartum with electrohysterography. Further investigation is recommended to improve diagnosis and treatment of postpartum hemorrhage.

Predictive Intelligent Control of Oxygenation in Preterm Infants: A Two-Center Feasibility Study.

INTRODUCTION: Supplemental oxygen therapy is a mainstay of modern neonatal intensive care for preterm infants. However, both insufficient and excess oxygen delivery are associated with adverse outcomes. Automated or closed loop FiO2 control has been developed to keep SpO2 within a predefined target range more effectively. METHODS: The aim of this study was to investigate the feasibility of closed loop FiO2 control by Predictive Intelligent Control of Oxygenation (PRICO) on the Fabian ventilator in maintaining SpO2 within a target range (88/89-95%) in preterm infants on different modes of invasive and noninvasive respiratory support. In two tertiary neonatal intensive care units, preterm infants with an FiO2 >0.21 were included and received an 8 h nonblinded treatment period of closed loop FiO2 control by PRICO, flanked by two 8 h control periods of routine manual control (RMC1 and RMC2). RESULTS: 32 preterm infants were included (median gestational age 26 + 5 weeks [IQR 25 + 5-27 + 6], median birthweight 828 grams [IQR 704-930]). Six patients received invasive respiratory support, while 26 received noninvasive respiratory support (18 CPAP, 4 DuoPAP, and 4 nasal IMV). The time percentage within the SpO2 target range was increased with PRICO (74.4% [IQR 67.8-78.5]) compared to RMC1 (65.8% [IQR 51.1-77.8]; p = 0.011) and RMC2 (60.6% [IQR 56.2-66.6]; p < 0.001) with an estimated median difference of 6.0% (95% CI 1.2-11.5) and 9.8% (95% CI 6.0-13.0), respectively. CONCLUSION: In preterm infants on invasive and noninvasive respiratory supports, closed loop FiO2 control by PRICO compared to RMC is feasible and superior in maintaining SpO2 within target ranges.

Short-Term Outcome after Repeated Less Invasive Surfactant Administration: A Retrospective Cohort Study.

INTRODUCTION: Less invasive surfactant administration (LISA) to preterm infants is associated with decreased risk for death or BPD. After LISA, a considerable proportion requires a second dose of surfactant because of ongoing respiratory distress syndrome, raising a clinical dilemma between intubation or performing a repeated LISA (re-LISA) procedure. We aim to assess efficacy of re-LISA in avoiding subsequent nasal continuous positive airway pressure failure (need for intubation in the first 72 h of life; CPAP-F), to identify factors associated with subsequent CPAP-F, and to compare short-term outcomes following re-LISA to surfactant retreatment by endotracheal intubation and mechanical ventilation. METHODS: This was an observational retrospective study in two Dutch NICUs. Inclusion criterion was infants with gestational age <32 0/7 weeks requiring a second surfactant dose. Multivariate logistic regression analysis was performed. RESULTS: Of 209 infants requiring second surfactant dose, 132 received re-LISA. Subsequent CPAP-F was observed in 56 (42%) infants and was associated with extreme prematurity (OR 2.6, 95% CI: 1.2-5.8) and FiO2>0.5 (OR 5.4, 95% CI: 2.0-14.7). Infants receiving re-LISA had a lower risk of death or BPD compared to infants intubated for the second surfactant dose (OR 0.4, 95% CI: 0.2-0.9). Infants with CPAP-F after re-LISA had similar outcomes compared to those intubated for second surfactant dose. CONCLUSION: Re-LISA is effective in reducing CPAP-F and is associated with lower risk of death or BPD compared to retreatment via an endotracheal tube. Infants failing CPAP after re-LISA have similar outcomes compared to intubated infants. These findings support the use of re-LISA in preterm infants with ongoing RDS.

Transferrin Saturation/Hepcidin Ratio Discriminates TMPRSS6-Related Iron Refractory Iron Deficiency Anemia from Patients with Multi-Causal Iron Deficiency Anemia.

Pathogenic TMPRSS6 variants impairing matriptase-2 function result in inappropriately high hepcidin levels relative to body iron status, leading to iron refractory iron deficiency anemia (IRIDA). As diagnosing IRIDA can be challenging due to its genotypical and phenotypical heterogeneity, we assessed the transferrin saturation (TSAT)/hepcidin ratio to distinguish IRIDA from multi-causal iron deficiency anemia (IDA). We included 20 IRIDA patients from a registry for rare inherited iron disorders and then enrolled 39 controls with IDA due to other causes. Plasma hepcidin-25 levels were measured by standardized isotope dilution mass spectrometry. IDA controls had not received iron therapy in the last 3 months and C-reactive protein levels were <10.0 mg/L. IRIDA patients had significantly lower TSAT/hepcidin ratios compared to IDA controls, median 0.6%/nM (interquartile range, IQR, 0.4-1.1%/nM) and 16.7%/nM (IQR, 12.0-24.0%/nM), respectively. The area under the curve for the TSAT/hepcidin ratio was 1.000 with 100% sensitivity and specificity (95% confidence intervals 84-100% and 91-100%, respectively) at an optimal cut-off point of 5.6%/nM. The TSAT/hepcidin ratio shows excellent performance in discriminating IRIDA from TMPRSS6-unrelated IDA early in the diagnostic work-up of IDA provided that recent iron therapy and moderate-to-severe inflammation are absent. These observations warrant further exploration in a broader IDA population.

Predictive Intelligent Control of Oxygenation (PRICO) in preterm infants on high flow nasal cannula support: a randomised cross-over study.

OBJECTIVE: To investigate the efficacy of automated control of inspired oxygen (FiO2) by Predictive Intelligent Control of Oxygenation (PRICO) on the Fabian ventilator in maintaining oxygen saturation (SpO2) in preterm infants on high flow nasal cannula (HFNC) support. DESIGN: Single-centre randomised two-period crossover study. SETTING: Tertiary neonatal intensive care unit. PATIENTS: 27 preterm infants (gestational age (GA) <30 weeks) on HFNC support with FiO2 >0.25. INTERVENTION: A 24-hour period on automated FiO2-control with PRICO compared with a 24-hour period on routine manual control (RMC) to maintain a SpO2 level within target range of 88%-95% measured at 30 s intervals. MAIN OUTCOME MEASURES: Primary outcome: time spent within target range (88%-95%). SECONDARY OUTCOMES: time spent above and below target range, in severe hypoxia (SpO2 <80%) and hyperoxia (SpO2 >98%), mean SpO2 and FiO2 and manual FiO2 adjustments. RESULTS: 15 patients received PRICO-RMC and 12 RMC-PRICO. The mean time within the target range increased with PRICO: 10.8% (95% CI 7.6 to 13.9). There was a decrease in time below target range: 7.6% (95% CI 4.2 to 11.0), above target range: 3.1% (95% CI 2.9 to 6.2) and in severe hypoxia: 0.9% (95% CI 1.5 to 0.2). We found no difference in time spent in severe hyperoxia. Mean FiO2 was higher during PRICO: 0.019 (95% CI 0.006 to 0.030). With PRICO there was a reduction of manual adjustments: 9/24 hours (95% CI 6 to 12). CONCLUSION: In preterm infants on HFNC support, automated FiO2-control by PRICO is superior to RMC in maintaining SpO2 within target range. Further validation studies with a higher sample frequency and different ventilation modes are needed.

The relationship between antenatal indomethacin as a tocolytic drug and neonatal outcomes: a retrospective cohort study.

INTRODUCTION: Preterm birth is associated with increased mortality and morbidity. Tocolytic drugs, such as indomethacin, are often used to postpone preterm delivery. Indomethacin has been proven to be more effective than other tocolytic agents in terms of delaying birth but is often prescribed with caution because of its potential association with adverse neonatal outcomes. We aim to study the effects of antenatal indomethacin on neonatal outcomes after controlling for potential confounders, as compared to nifedipine and/or atosiban. METHODS: In this cohort study, we performed a retrospective analysis of maternal and neonatal data. Women were included if they received indomethacin, nifedipine or atosiban as a tocolytic drug for imminent preterm labor and gave birth at a gestational age (GA) between 235/7 and 320/7 weeks, between 2010 and 2015. Main outcome measures were: neonatal death, necrotizing enterocolitis (NEC), spontaneous intestinal perforation (SIP), intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), patent ductus arteriosus (PDA) and its treatment. RESULTS: Four hundred seventy-four women, delivering 610 infants were investigated. The incidence of the following adverse neonatal outcomes were significantly higher after indomethacin use: neonatal death (p = .017), NEC (p = .026), SIP (p = .008), PDA (p = .000) and PDA ligation (p = .000). However, these associations showed to be nonsignificant after adjusting for confounders (adjusted odds ratio neonatal mortality 1.6 (0.7-3.8)), NEC 1.6 (0.6-4.4), SIP 2.8 (0.3-30.0), PDA 1.1 (0.6-2.2) and PDA ligation 2.2 (0.7-6.5). CONCLUSIONS: The presumed association between antenatal indomethacin exposure and several adverse neonatal outcomes may be based upon indication bias. Taking important confounding factors, such as GA at birth and neonatal birth weight into account, antenatal indomethacin exposure does not result in a higher incidence of adverse neonatal outcomes. However, there may be a higher risk for spontaneous intestinal perforation.

The effect of intrauterine resuscitation by maternal hyperoxygenation on perinatal and maternal outcome: a randomized controlled trial.

BACKGROUND: Maternal hyperoxygenation is widely used during labor as an intrauterine resuscitation technique. However, robust evidence regarding its beneficial effect and potential side effects is scarce, and previous studies show conflicting results. OBJECTIVE: To assess the effect of maternal hyperoxygenation upon suspected fetal distress during the second stage of term labor on fetal heart rate, neonatal outcome, maternal side effects, and mode of delivery. MATERIALS AND METHODS: In a single-center randomized controlled trial in a tertiary hospital in The Netherlands, participants were randomized in case of an intermediary or abnormal fetal heart rate pattern during the second stage of term labor, to receive either conventional care or 100% oxygen at 10 L/min until delivery. The primary outcome was the change in fetal heart rate pattern. Prespecified secondary outcomes were Apgar score, umbilical cord blood gas analysis, neonatal intensive care unit admission, perinatal death, free oxygen radical activity, maternal side effects, and mode of delivery. We performed subgroup analyses for intermediary and abnormal fetal heart rate, and for small for gestational age fetuses. RESULTS: From March 2016 through April 2018, a total of 117 women were included. Fetal heart rate patterns could be analyzed in 71 women. Changes in fetal heart rate (defined as improvement, equal, or deterioration) in favor of maternal hyperoxygenation were significant (odds ratio, 5.7; 95% confidence interval, 1.7-19.1) using ordinal logistic regression. Apgar score, umbilical cord blood gas analysis, free oxygen radicals, and mode of delivery showed no significant differences between the intervention and control group. Among women with an abnormal fetal heart rate, there were fewer episiotomies on fetal indication in the intervention group (25%) than in the control group (65%, P < .01). CONCLUSION: Maternal hyperoxygenation has a positive effect on the fetal heart rate in the presence of suspected fetal distress during the second stage of labor. There was no significant difference in the mode of delivery or neonatal outcome; however, significantly fewer episiotomies on fetal indication were performed following maternal hyperoxygenation in the subgroup with abnormal fetal heart rate pattern.

Qualitative assessment of interpretability and observer agreement of three uterine monitoring techniques.

OBJECTIVE: The aim of this research was to assess the quality and inter- and intra-observer agreement of tracings obtained by three different techniques for uterine contraction monitoring: the external tocodynamometer (TOCO), the intrauterine pressure catheter (IUPC) and a recently introduced method based on electrohysterography (EHG). STUDY DESIGN: We included 150 uterine activity registrations from a previous prospective observational study (W3 study), conducted at Máxima Medical Centre in Veldhoven, the Netherlands. Term singleton pregnant women were simultaneously monitored with TOCO, IUPC and EHG during labor. Six clinicians, blinded to the source (TOCO, IUPC, or EHG) and subject, evaluated all tracings that were subsequently presented in random order. They annotated contractions and assigned each tracing a score for interpretability of 2 (good), 1 (moderate) or 0 (poor). To evaluate inter-observer agreement, we calculated kappa values for the qualitative assessment, and intraclass correlation coefficients (ICC) for the number of contractions annotated by clinicians. Four clinicians repeated this procedure to evaluate intra-observer agreement. RESULTS: IUPC tracings received the highest quality rating, with a mean score of 1.95, followed by a mean score of 1.60 for EHG and 0.80 for TOCO (p < 0.05). Mean weighted kappa values were 0.63 for TOCO and 0.45 for EHG. The average number of contractions that was picked up by clinicians was 59.8 for the intrauterine pressure catheter, 49.8 for EHG and 26.4 for TOCO. The ICC of the intrauterine pressure catheter was significantly higher than the external methods, regarding both inter- and intra-observer agreement (0.98 and 0.99 respectively). CONCLUSION: IUPC recordings scored best regarding quality, inter- and intra-observer agreement. However, due to safety issues, in many countries this technique is not used anymore. The quality of TOCO was rated as poor and many contractions were missed as compared to the gold standard. From a clinical interpretational point of view, EHG is favorable to TOCO. EHG recordings were assigned higher quality scores, but with less agreement between clinicians. An explanation could be that EHG is a relatively new technique, while IUPC and the TOCO are being used for decades. Building experience with EHG (training) is therefore recommended.

Changes in body weight and serum liver tests associated with parenteral nutrition compared with no parenteral nutrition in patients with acute myeloid leukemia during remission induction treatment.

PURPOSE: Differences in body weight changes and serum liver tests (LTs) in acute myeloid leukemia (AML) patients receiving parenteral nutrition (PN) versus no PN during remission induction (RI) treatment were assessed. METHODS: Retrospectively, differences in body weight changes and serum LTs in AML patients (n = 213) who received PN versus no PN during RI treatment in one of three Dutch hospitals between 2004 and 2015 were assessed. Weekly body weight and serum LT registrations were collected from medical records. Patients' body weight changes were compared between the hospitals where PN is applied upon first indication of inadequate oral intake (PN hospitals) and the hospital where use of PN is limited to severe cases only (no-PN hospital) using repeated measures mixed model analysis. Differences in severity of serum LT elevations, according to the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0, were assessed between patients who did and did not receive PN using chi-square or Fisher's exact tests, and multiple logistic regression analysis. RESULTS: Compared with patients of the PN hospitals, patients of the no-PN hospital experienced significantly more body weight loss during RI treatment (between-group difference 7.2%, 95% CI 4.0-10.3%). Furthermore, PN was associated with transient mild to moderate elevations of liver enzymes, but not with raised median total bilirubin levels nor with occurrence of CTCAE grade 3-4 LT elevations. CONCLUSION: Frequent compared with exceptional use of PN in AML patients during RI treatment better preserved body weight, without clinically relevant (CTCAE grade 3-4) elevations in serum LTs.

Minimally invasive surfactant therapy failure: risk factors and outcome.

OBJECTIVE: To evaluate incidence of minimally invasive surfactant therapy (MIST) failure, identify risk factors and assess the impact of MIST failure on neonatal outcome. DESIGN: Retrospective cohort study. MIST failure was defined as need for early mechanical ventilation (<72 hours of life). Multivariate logistic regression analysis was performed to identify risk factors for MIST failure and compare outcomes between groups. SETTING: Two tertiary neonatal intensive care centres in the Netherlands. PATIENTS: Infants born between 24 weeks' and 31 weeks' gestational age (GA) (n=185) with MIST for respiratory distress syndrome. INTERVENTIONS: MIST procedure with poractant alfa (100-200 mg/kg). MAIN OUTCOME MEASURES: Continuous positive airway pressure (CPAP) failure after MIST in the first 72 hours of life. RESULTS: 30% of the infants failed CPAP after MIST. In a multivariate logistic regression analysis, four risk factors were independently associated with failure: GA <28 weeks, C reactive protein ≥10 mg/L, absence of antenatal corticosteroids and lower surfactant dose. Infants receiving 200 mg/kg surfactant had a failure rate of 14% versus 35% with surfactant dose <200 mg/kg. Mean body temperature was 0.4°C lower at neonatal intensive care unit admission and before the procedure in infants with MIST failure.Furthermore, MIST failure was independently associated with an increased risk of severe intraventricular haemorrhage. CONCLUSION: We observed moderate MIST failure rates in concordance with the results of earlier studies. Absence of corticosteroids and lower surfactant dose are risk factors for MIST failure that may be modifiable in order to improve MIST success and patient outcome.

Performance of the Manchester triage system in older emergency department patients: a retrospective cohort study.

BACKGROUND: Studies on the reliability of the MTS and its predictive power for hospitalisation and mortality in the older population have demonstrated mixed results. The objective is to evaluate the performance of the Manchester Triage System (MTS) in older patients (≥65 years) by assessing the predictive ability of the MTS for emergency department resource utilisation, emergency department length of stay (ED-LOS), hospitalisation, and in-hospital mortality rate. The secondary goal was to evaluate the performance of the MTS in older surgical versus medical patients. METHODS: A retrospective cohort study was conducted of all emergency department visits by patients ≥65 years between 01 and 09-2011 and 31-08-2012. Performance of the MTS was assessed by comparing the association of the MTS with emergency department resource utilisation, ED-LOS, hospital admission, and in-hospital mortality in older patients and the reference group (18-64 years), and by estimating the area under the receiver operating characteristics curves. RESULTS: Data on 7108 emergency department visits by older patients and 13,767 emergency department visits by patients aged 18-64 years were included. In both patient groups, a higher emergency department resource utilisation was associated with a higher MTS urgency. The AUC for the MTS and hospitalisation was 0.74 (95%CI 0.73-0.75) in older patients and 0.76 (95%CI 0.76-0.77) in patients aged 18-64 years. Comparison of the predictive ability of the MTS for in-hospital mortality in older patients with patients aged 18-64 years revealed an AUC of 0.71 (95%CI 0.68-0.74) versus 0.79 (95%CI 0.72-0.85). The majority of older patients (54.8%) were evaluated by a medical specialty and 45.2% by a surgical specialty. The predictive ability of the MTS for hospitalisation and in-hospital mortality was higher in older surgical patients than in medical patients (AUC 0.74, 95%CI 0.72-0.76 and 0.74, 95%CI 0.68-0.81 versus 0.69, 95%CI 0.67-0.71 and 0.66, 95%CI 0.62-0.69). CONCLUSION: The performance of the MTS appeared inferior in older patients than younger patients, illustrated by a worse predictive ability of the MTS for in-hospital mortality in older patients. The MTS demonstrated a better performance in older surgical patients than older medical patients regarding hospitalisation and in-hospital mortality.

Uterine Monitoring Techniques from Patients' and Users' Perspectives.

Objective To evaluate preferences from patients and users on 3 uterine monitoring techniques, during labor. Study Design Women in term labor were simultaneously monitored with the intrauterine pressure catheter, the external tocodynamometer, and the electrohysterograph. Postpartum, these women filled out a questionnaire evaluating their preferences and important aspects. Nurses completed a questionnaire evaluating users' preferences. Results Of all 52 participating women, 80.8% preferred the electrohysterograph, 17.3% the intrauterine pressure catheter and 1.9% the external tocodynamometer. For these women, the electrohysterograph scored best regarding application and presence during labor ( p < 0.001). Most important aspects were "least likely to harm" and "least discomfort". Of 57 nurses, 40.4% preferred the electrohysterograph, 35.1% the external tocodynamometer, and 24.6% had no preference, or replied that their preference is subject to situation and patient. Conclusion Patients prefer the electrohysterograph over the external tocodynamometer and the intrauterine pressure catheter, while healthcare providers report ambiguous results.

Outcome of elderly emergency department patients hospitalised on weekends - a retrospective cohort study.

BACKGROUND: Studies investigating different medical conditions and settings have demonstrated mixed results regarding the weekend effect. However, data on the outcome of elderly patients hospitalised on weekends is scarce. The objective was to compare in-hospital and two-day mortality rates between elderly emergency department (ED) patients (≥65 years) admitted on weekends versus weekdays. METHODS: A retrospective cohort study of emergency department visits of internal medicine patients ≥65 years presenting to the emergency department between 01 and 09-2010 and 31-08-2012 was conducted. The weekend was defined as the period from midnight on Friday to midnight on Sunday. RESULTS: Data on 3697 emergency department visits by elderly internal medicine patients (mean age 78.6 years old) were included. In total, 2743 emergency department visits (74.2%) resulted in hospitalisation, of which 22.9% occurred on weekends. Comorbidity and urgency levels were higher in patients admitted on weekends. In-hospital mortality was 11.4% for patients admitted on weekends compared with 8.9% on weekdays (OR 1.3, 95%CI 0.99-1.8). Two-day mortality was 3.2% in patients hospitalised on weekends versus 1.9% on weekdays (OR 1.7, 95%CI 0.99-2.9). Multivariable adjustment for age, comorbidity and triage level demonstrated comparable in-hospital and two-day mortality for weekend and week admission (ORadj 1.2, 95%CI 0.9-1.7 and ORadj 1.5, 95%CI 0.8-2.6, resp.). CONCLUSION: A small weekend effect was observed in elderly internal medicine patients, which was not statistically significant. This effect was partly explained by a higher comorbidity and urgency level in elderly patients hospitalised on weekends than during weekdays. Emergency care for the elderly is not compromised by adjusted logistics during the weekend.

The influence of betamethasone on fetal heart rate variability, obtained by non-invasive fetal electrocardiogram recordings.

BACKGROUND: Betamethasone is widely used to enhance fetal lung maturation in case of threatened preterm labour. Fetal heart rate variability is one of the most important parameters to assess in fetal monitoring, since it is a reliable indicator for fetal distress. AIM: To describe the effect of betamethasone on fetal heart rate variability, by applying spectral analysis on non-invasive fetal electrocardiogram recordings. STUDY DESIGN: Prospective cohort study. SUBJECTS: Patients that require betamethasone, with a gestational age from 24 weeks onwards. OUTCOME MEASURES: Fetal heart rate variability parameters on day 1, 2, and 3 after betamethasone administration are compared to a reference measurement. RESULTS: Following 68 inclusions, 12 patients remained with complete series of measurements and sufficient data quality. During day 1, an increase in absolute fetal heart rate variability values was seen. During day 2, a decrease in these values was seen. All trends indicate to return to pre-medication values on day 3. Normalised high- and low-frequency power show little changes during the study period. CONCLUSIONS: The changes in fetal heart rate variability following betamethasone administration show the same pattern when calculated by spectral analysis of the fetal electrocardiogram, as when calculated by cardiotocography. Since normalised spectral values show little changes, the influence of autonomic modulation seems minor.

Could electrohysterography be the solution for external uterine monitoring in obese women?

OBJECTIVE: To evaluate the influence of maternal obesity on the performance of external tocodynamometry and electrohysterography. STUDY DESIGN: In a 2-hour measurement during term labor, uterine contractions were simultaneously measured by electrohysterography, external tocodynamometry, and intra-uterine pressure catheter. The sensitivity was compared between groups based on obesity (non-obese/obese/morbidly obese) or uterine palpation (good/moderate/poor), and was correlated to maternal BMI and abdominal circumference. RESULT: We included 14 morbidly obese, 18 obese, and 20 non-obese women. In morbidly obese women, the median sensitivity was 87.2% (IQR 74-93) by electrohysterography and 45.0% (IQR 36-66) by external tocodynamometry (p < 0.001). The sensitivity of electrohysterography appeared to be non-influenced by obesity category (p = 0.279) and uterine palpation (p = 0.451), while the sensitivity of tocodynamometry decreased significantly (p = 0.005 and p < 0.001, respectively). Furthermore, the sensitivity of both external methods was negatively correlated with obesity parameters, being non-significant for electrohysterography (range p-values 0.057-0.088) and significant for external tocodynamometry (all p-values < 0.001). CONCLUSIONS: Electrohysterography performs significantly better than external tocodynamometry in case of maternal obesity.

Elderly emergency patients presenting with non-specific complaints: Characteristics and outcomes.

BACKGROUND: Non-specific complaints (NSC) are common at the emergency department, but only a few studies have shown evidence that these complaints are associated with a poor prognosis in elderly emergency patients. OBJECTIVE: To describe patient characteristics and outcomes in a cohort of elderly emergency patients presenting with NSC. Outcomes were: patient characteristics, hospitalization, 90-day ED-return visits, and 30-day mortality. METHOD: A retrospective cohort study was conducted amongst elderly patients present to the Internal Medicine Emergency Department (ED) between 01-09-2010 and 31-08-2011. NSC were defined as indefinable complaints that lack a pre-differential diagnosis needed to initiate of a standardized patient evaluation. Cox regression was performed to calculate Hazard Ratios (HR) and corrected for confounders such as comorbidity. RESULTS: In total, 1784 patients were enrolled; 244 (13.7%) presented with NSC. Compared to those with SC, comorbidity was higher in the NSC-group (Charlson comorbidity index 3.0 vs. 2.4, p<0.001). The triage level did not differ, but ED-length of stay was longer in the NSC-group (188 vs. 178 minutes, p = 0.004). Hospitalization was more frequent (84.0 vs. 71.1%, p<0.001) and the length of hospital stay (9 vs. 6 days, p<0.001 was longer in the NSC- than in the SC-group. The number of ED-return visits were comparable between both groups (HR 0.8, 95%CI 0.6-1.1). Mortality within 30-days was higher in the NSC- (20.1%) than in the SC-group (11.0%, HR 1.7 95%CI 1.2-2.4). CONCLUSION: Elderly patients present with NSC at the ED regularly. These patients are more often hospitalized and have a substantially higher 30-day mortality than patients with SC.

Electrohysterography for uterine monitoring during term labour compared to external tocodynamometry and intra-uterine pressure catheter.

OBJECTIVE: Current uterine monitoring techniques have major drawbacks that could be avoided when using electrohysterography for uterine monitoring. Recently, a new electrohysterography method has been developed, providing a real-time tocogram on standard cardiotocography monitors. The diagnostic characteristics of this novel method need to be determined and compared to conventional methods We hypothesised that electrohysterography can perform better than external tocodynamometry due to the adhesive properties of the contact electrodes (less motion sensitive), and the improved signal acquisition through subcutaneous tissue (less obesity sensitive). STUDY DESIGN: In this prospective diagnostic accuracy study, uterine contractions of labouring women were simultaneously monitored by three different monitoring techniques: electrohysterography, external tocodynamometry, and intra-uterine pressure catheter as method of reference. We performed a two-hour measurement during first and/or second stage of term labour. The contractions of each method were automatically detected by a computer-based algorithm. As the applied method had not been described in literature before, an interim analysis was performed to minimise exposure to the invasive pressure catheter. The main outcome parameter was the sensitivity of electrohysterography in comparison to external tocodynamometry for uterine contraction detection, tested by the Wilcoxon signed rank test. RESULTS: Uterine contractions of 48 term labouring women were simultaneously monitored by electrohysterography, external tocodynamometry, and intra-uterine pressure catheter. The study was terminated after the interim analysis as the sensitivity of electrohysterography was significantly higher compared to external tocodynamometry: median 89.5% (interquartile range (IQR); 82-93) and 65.3% (IQR; 53-81) respectively, p<0.001. In a subgroup analysis of obese women (n=15), the sensitivity of electrohysterography was significantly higher than external tocodynamometry (median 88.4% (IQR; 79-95) and 45.8% (IQR; 38-61) respectively, p<0.001). Whereas in a subanalysis of second stage of labour (n=8), electrohysterography did not perform better than external tocodynamometry (median 72.8% (IQR; 61-87) and 66.4% (IQR; 46-75) respectively, p=0.225). Electrohysterography registered 0.4 more contractions per 10min than the intra-uterine pressure measurement (p<0.001) and 0.5 more contractions per 10min than external tocodynamometry (p<0.001). CONCLUSION: Electrohysterography has a higher sensitivity for uterine contraction detection than external tocodynamometry during first stage of labour, in non-obese and obese women. Electrohysterography identifies more contractions than conventional techniques.

Risk factors of incomplete Apgar score and umbilical cord blood gas analysis: a retrospective observational study.

OBJECTIVE: To investigate whether incomplete umbilical cord blood gas (UCBG) analysis occurs more often than the incomplete reporting of the Apgar score, and risk factors associated with the incomplete values. METHODS: A total of 8824 infants born alive after 26 weeks' gestation between January 2009 and April 2013 were included. We extracted data on five-minute Apgar score, UCBG analysis, gestational age, mode of delivery, time of delivery and multiple pregnancy. Univariate and multivariable logistic regression analyses were performed. RESULTS: Five-minute Apgar score was incomplete in 15 cases (0.2%) and UCBG analysis in 1960 cases (22.2%), p < 0.05. Incomplete UCBG analysis was significantly more likely to occur in situations with Apgar score below seven (Odds ratio (OR) 1.68, 95% CI;1.29-2.19), gestational age between 26 to 27 6/7 and 28 to 31 6/7 weeks (OR 3.14, 95% CI; 2.13-4.62 and OR 1.91, 95% CI; 1.57-2.32), cesarean section (OR 1.31, 95% CI; 1.11-1.55), and multiple pregnancy (OR 2.02, 95% CI; 1.69-2.43). Deliveries during night time had a lower risk of incomplete UCBG analysis (OR 0.78, 95% CI; 0.69-0.88). CONCLUSIONS: Measuring five-minute Apgar score generated less incomplete data compared with UCBG analysis. The risk factors associated with incomplete UCBG analysis were noted. Study outcomes with UCBG analysis as neonatal assessment tool should be interpreted with caution.

Pain coping strategies: Neonatal intensive care unit survivors in adolescence.

BACKGROUND: Data on long-term consequences of preterm birth on pain coping later in life are limited. AIM: To assess whether gestational age, birth weight and neonatal disease severity have effect on pain coping style in adolescents born preterm or with low birth weight. STUDY DESIGN: Observational, longitudinal study (Project On Preterm and SGA-infants, POPS-19). SUBJECTS: We analyzed data of 537 adolescents at the age of 19 years, who were born at a gestational age <32 weeks or with a birth weight <1500g. OUTCOME MEASURES: Participants completed the pain coping questionnaire (PCQ) that assesses pain coping strategies in three higher-order factors: approach ("to deal with pain"), problem-focused avoidance ("to disengage from pain") and emotion-focused avoidance ("expression of pain"). Furthermore, their pain coping effectiveness, pain controllability and emotional reactions to pain were assessed. All participants completed an IQ test. RESULTS: Univariate analysis showed no significant correlation between length of stay, sepsis and necrotizing enterocolitis and any of the higher-order factors. Approach was only correlated with IQ. Problem-focused avoidance was, in the multiple regression analysis (including gestational age, IVH and IQ), only correlated with IQ. For emotion-focused avoidance (including birth weight, SGA, IVH, respiratory support and IQ) three independent predictors remained: IVH was positively correlated, while respiratory support and IQ were negatively correlated with emotion-focused avoidance. CONCLUSIONS: Early neonatal characteristics and neonatal disease severity have limited effect on pain coping style in adolescence. Higher IQ was associated with the use of adaptive coping strategies, while maladaptive strategies were used less.

The impact of transmural multiprofessional simulation-based obstetric team training on perinatal outcome and quality of care in the Netherlands.

BACKGROUND: Perinatal mortality and morbidity in the Netherlands is relatively high compared to other European countries. Our country has a unique system with an independent primary care providing care to low-risk pregnancies and a secondary/tertiary care responsible for high-risk pregnancies. About 65% of pregnant women in the Netherlands will be referred from primary to secondary care implicating multiple medical handovers. Dutch audits concluded that in the entire obstetric collaborative network process parameters could be improved. Studies have shown that obstetric team training improves perinatal outcome and that simulation-based obstetric team training implementing crew resource management (CRM) improves team performance. In addition, deliberate practice (DP) improves medical skills. The aim of this study is to analyse whether transmural multiprofessional simulation-based obstetric team training improves perinatal outcome. METHODS/DESIGN: The study will be implemented in the south-eastern part of the Netherlands with an annual delivery rate of over 9,000. In this area secondary care is provided by four hospitals. Each hospital with referring primary care practices will form a cluster (study group). Within each cluster, teams will be formed of different care providers representing the obstetric collaborative network. CRM and elements of DP will be implemented in the training. To analyse the quality of care as perceived by patients, the Pregnancy and Childbirth Questionnaire (PCQ) will be used. Furthermore, self-reported collaboration between care providers will be assessed. Team performance will be measured by the Clinical Teamwork Scale (CTS). We employ a stepped-wedge trial design with a sequential roll-out of the trainings for the different study groups.Primary outcome will be perinatal mortality and/or admission to a NICU. Secondary outcome will be team performance, quality of care as perceived by patients, and collaboration among care providers. CONCLUSION: The effect of transmural multiprofessional simulation-based obstetric team training on perinatal outcome has never been studied. We hypothesise that this training will improve perinatal outcome, team performance, and quality of care as perceived by patients and care providers. TRIAL REGISTRATION: The Netherlands National Trial Register, http://www.trialregister.nl/NTR4576, registered June 1, 2014.