Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe.

BACKGROUND: The EUropean Project on obstetric Haemorrhage Reduction: Attitudes, Trial, and Early warning System (EUPHRATES) is a set of five linked projects, the first component of which was a survey of policies for management of the third stage of labour and immediate management of postpartum haemorrhage following vaginal birth in Europe. OBJECTIVES: The objectives were to ascertain and compare policies for management of the third stage of labour and immediate management of postpartum haemorrhage in maternity units in Europe following vaginal birth. DESIGN: Survey of policies. SETTING: The project was a European collaboration, with participants in 14 European countries. SAMPLE: All maternity units in 12 countries and in selected regions of two countries in Europe. METHODS: A postal questionnaire was sent to all or a defined sample of maternity units in each participating country. MAIN OUTCOME MEASURES: Stated policies for management of the third stage of labour and the immediate management of postpartum haemorrhage. RESULTS: Policies of using uterotonics for the management of the third stage were widespread, but policies about agents, timing, clamping and cutting the umbilical cord and the use of controlled cord traction differed widely. For immediate management of postpartum haemorrhage, policies of massaging the uterus were widespread. Policies of catheterising the bladder, bimanual compression and in the choice of drugs administered were much more variable. CONCLUSIONS: Considerable variations were observed between and within countries in policies for management of the third stage of labour. Variations were observed, but to a lesser extent, in policies for the immediate management of postpartum haemorrhage after vaginal birth. In both cases, policies about the pharmacological agents to be used varied widely.

Should euthanasia be legal? An international survey of neonatal intensive care units staff.

OBJECTIVE: To present the views of a representative sample of neonatal doctors and nurses in 10 European countries on the moral acceptability of active euthanasia and its legal regulation. DESIGN: A total of 142 neonatal intensive care units were recruited by census (in the Netherlands, Sweden, Hungary, and the Baltic countries) or random sampling (in France, Germany, Italy, Spain, and the United Kingdom); 1391 doctors and 3410 nurses completed an anonymous questionnaire (response rates 89% and 86% respectively). MAIN OUTCOME MEASURE: The staff opinion that the law in their country should be changed to allow active euthanasia "more than now". RESULTS: Active euthanasia appeared to be both acceptable and practiced in the Netherlands, France, and to a lesser extent Lithuania, and less acceptable in Sweden, Hungary, Italy, and Spain. More then half (53%) of the doctors in the Netherlands, but only a quarter (24%) in France felt that the law should be changed to allow active euthanasia "more than now". For 40% of French doctors, end of life issues should not be regulated by law. Being male, regular involvement in research, less than six years professional experience, and having ever participated in a decision of active euthanasia were positively associated with an opinion favouring relaxation of legal constraints. Having had children, religiousness, and believing in the absolute value of human life showed a negative association. Nurses were slightly more likely to consider active euthanasia acceptable in selected circumstances, and to feel that the law should be changed to allow it more than now. CONCLUSIONS: Opinions of health professionals vary widely between countries, and, even where neonatal euthanasia is already practiced, do not uniformly support its legalisation.

Neonatal end-of-life decision making: Physicians' attitudes and relationship with self-reported practices in 10 European countries.

CONTEXT: The ethical issues surrounding end-of-life decision making for infants with adverse prognoses are controversial. Little empirical evidence is available on the attitudes and values that underlie such decisions in different countries and cultures. OBJECTIVE: To explore the variability of neonatal physicians' attitudes among 10 European countries and the relationship between such attitudes and self-reported practice of end-of-life decisions. DESIGN AND SETTING: Survey conducted during 1996-1997 in 10 European countries (France, Germany, Italy, the Netherlands, Spain, Sweden, the United Kingdom, Estonia, Hungary, and Lithuania). PARTICIPANTS: A total of 1391 physicians (response rate, 89%) regularly employed in 142 neonatal intensive care units (NICUs). MAIN OUTCOME MEASURES: Scores on an attitude scale, which measured views regarding absolute value of life (score of 0) vs value of quality of life (score of 10); self-report of having ever set limits to intensive neonatal interventions in cases of poor neurological prognosis. RESULTS: Physicians more likely to agree with statements consistent with preserving life at any cost were from Hungary (mean attitude scores, 5.2 [95% confidence interval ¿CI¿, 4.9-5.5]), Estonia (4.9 [95% CI, 4.3-5.5]), Lithuania (5.5 [95% CI, 4.8-6.1]), and Italy (5.7 [95% CI, 5.3-6.0]), while physicians more likely to agree with the idea that quality of life must be taken into account were from the United Kingdom (attitude scores, 7.4 [95% CI, 7.1-7.7]), the Netherlands (7. 3 [95% CI, 7.1-7.5]), and Sweden (6.8 [95% CI, 6.4-7.3]). Other factors associated with having a pro-quality-of-life view were being female, having had no children, being Protestant or having no religious background, considering religion as not important, and working in an NICU with a high number of very low-birth-weight newborns. Physicians with scores reflecting a more quality-of-life view were more likely to report that in their practice, they had set limits to intensive interventions in cases of poor neurological prognosis, with an adjusted odds ratio of 1.5 (95% CI, 1.3-1.7) per unit change in attitude score. CONCLUSIONS: In our study, physicians' likelihood of reporting setting limits to intensive neonatal interventions in cases of poor neurological prognosis is related to their attitudes. After adjusting for potential confounders, country remained the most important predictor of physicians' attitudes and practices. JAMA. 2000;284:2451-2459.

Treatment choices for extremely preterm infants: an international perspective.

OBJECTIVE: To compare treatment choices of neonatal physicians and nurses in 11 European countries for a hypothetical case of extreme prematurity (24 weeks' gestational age, birth weight of 560 g, Apgar score of 1 at 1 minute). STUDY DESIGN: An anonymous, self-administered questionnaire was completed by 1401 physicians (response rate, 89%) and 3425 nurses (response rate, 86%) from a large, representative sample of 143 European neonatal intensive care units. Italy, Spain, France, Germany, the Netherlands, Luxembourg, Great Britain, Sweden, Hungary, Estonia, and Lithuania participated. RESULTS: Most physicians in every country but the Netherlands would resuscitate this baby and start intensive care. On subsequent deterioration of clinical conditions caused by a severe intraventricular hemorrhage, attitudes diverge: most neonatologists in Germany, Italy, Estonia, and Hungary would favor continuation of intensive care, whereas in the other countries some form of limitation of treatment would be the preferred choice. Parental wishes appear to play a role especially in Great Britain and the Netherlands. Nurses are more prone than doctors to withhold resuscitation in the delivery room and to ask parental opinion regarding subsequent treatment choices. CONCLUSION: An extremely premature infant is regarded as viable by most physicians, whereas after deterioration of the clinical conditions decision-making patterns vary according to country. These findings have implications for the ethical debate surrounding treatment of infants of borderline viability and for the interpretation and comparison of international statistics.

Epidemiological study of Chlamydia trachomatis infection in pregnant women in Hungary.

A multicentre survey was carried out in order to determine the prevalence and risk factors of Chlamydia trachomatis infection in the pregnant population in Hungary. The nucleic acid hybridisation method (PACE 2 Gen-Probe) was applied for the examination of C trachomatis. The overall average prevalence of C trachomatis cases during an 18 month survey on 6161 pregnant women was 5.87%. There were significant differences in the proportions of chlamydial infection in the different survey centres, and also in the different age groups and the different family status groups. The perinatal mortality rate exhibited a significantly higher prevalence (8.52%) among C trachomatis positive than among negative patients (2.03%). In the anamnestic histories of C trachomatis infected patients, the frequency of premature uterine activity was 8.13%, in contrast with 5.18% in the non-infected group (p < 0.05). We suggest that all pregnant women be tested for C trachomatis infection.

The frequency and the role of Chlamydia trachomatis infection in premature labor.

OBJECTIVE: The importance of Chlamydia trachomatis (C. tr.) infection in the etiology of premature labor was examined in a prospective, representative, multicenter study. METHOD: Specimens were collected from 6161 subjects in seven centers and examined by the Gen-Probe method. RESULTS: The infection rate was 5.74%. There were no significant correlations between low birth weight, premature rupture of the membranes, dysmaturity and C. tr. infection. In cases of threatening premature labor, the infection rate was significantly higher in C. tr.-positive patients. In the event of combined low birth weight and perinatal death, the maternal C. tr. infection rate was significantly higher than in normal pregnancies. C. tr.-positive patients treated with roxithromycin had term deliveries. A correlation between poor social circumstances and a high C. tr. infection rate could be proved. CONCLUSION: Cases with a poor obstetric history and/or socially high-risk patients should be screened for C. tr. infection, and in positive cases treatment is recommended.

Prevalence of Chlamydia trachomatis infection in a low-risk population in Hungary.

BACKGROUND AND OBJECTIVE: Chlamydia trachomatis is the leading cause of nongonococcal urethritis and cervicitis in women. Because of the recent increases in the numbers of new cases and severe consequences, there is an urgent demand for the introduction of sensitive and specific rapid diagnostic methods. GOAL: A multicenter examination involving seven centers was sponsored by the Hungarian Ministry of Health and Welfare in order to provide a survey of Chlamydia trachomatis in the gravid population. 6,161 women were tested between 1994 to 1995. STUDY DESIGN: The seven centers were selected with regard to different aspects, from developed and less developed areas in the capital, two large provincial towns, and various other provincial regions reflecting either an industrial or an agricultural background. The nucleic acid hybridization method (PACE 2 Gen-Probe, San Diego, CA) was introduced in this low-risk population for the examination of Chlamydia trachomatis. In one center, a further two methods, antigen detection by ELISA (SYVA, CA) and cultivation on the McCoy cell line (staining with SYVA FITC-labeled antichlamydia monoclonal antibody), were applied. RESULTS: International surveys and experience indicate that the proportion of the population threatened by Chlamydia trachomatis is above 10%. The overall average incidence of Chlamydia trachomatis cases in this low-risk gravid population was 5.74%. The data from the different centers ranged between 1.6% and 9.7%. The chlamydia-infected Hungarian gravid population is below the critical 10%, but there is one Hungarian county where the value is close to 10%. CONCLUSIONS: In this provincial, industrial area, the number of unmarried and divorced gravida in a low economic situation is disproportionately high. For this disadvantaged population, permanent Chlamydia trachomatis screening was suggested. In the other centers, screening of pregnant women for Chlamydia trachomatis and the treatment of positive cases and their partners were suggested for pathological gravida with preterm labor and preterm rupture of the membranes.

The clinical importance of bacterial urinary tract infections during pregnancy. I. Premature delivery, dismaturity.

Using computer analysis the authors studied the relationship between the various clinical forms of urinary tract infections and premature deliveries, i.e. dysmaturity in a population including several thousands of individuals. In the frameworks of uniform and monitored perinatal obstetric and neonatologic care system--the uniform diagnostics of bacteriuria was established. The standard birth-weights for the regions involved by our care were calculated, too. The basic observations of Kass were still found to be valid. In case of urinary tract infections, an increased rate of premature deliveries with respect to both birth-weights and gestational age of pregnancy should be reckoned with. Computer analysis proved not only a tendency for premature deliveries but also retarded intrauterine growth of the foetus.

The clinical importance of bacterial urinary tract infections during pregnancy. II. Events during delivery.

Inertia in labour could be more often observed and the number of intra-uterine foetal distress signs increased in case of bacterial infection of the maternal uropoietic and urinary system. Consequently, stimulation of labour pains and surgical termination of the delivery were required several times. The data in concert with those mentioned in the first part of the study indicate that the clinical pictures associated with the bacterial infections of the urine constitute a significant part of the pathological aspects of pregnancy.

The clinical importance of urinary tract infections during pregnancy. III. Neonatal morbidity and mortality.

The third part of the series shows that the various forms of maternal urinary tract infections have a negative effect on the newborn. Already at birth, there are several depressed babies in need of resuscitation. The frequency of prolonged jaundice requiring treatment has been increasing. The babies are more predisposed to infections. Congenital pneumonia more often occurs. As a result, the exposure of babies to drugs and x-rays is greater and perinatal mortality is higher. The newborn are much frailer than they should be on the basis of the frequency of their prematurity. The epidemiological analysis raises the possibility of the harmful effect of intrauterine infections in bacteriuric and pyelonephritic pregnancies.