Suboptimal care and perinatal mortality in ten European regions: methodology and evaluation of an international audit.

BACKGROUND: A European concerted action (the EuroNatal study) investigated differences in perinatal mortality between countries of Europe. This report describes the methods used in the EuroNatal international audit and discusses the validity of the results. METHODS: Perinatal deaths between 1993 and 1998 in regions of ten European countries were identified. The categories of death chosen for the study were singleton fetal deaths at 28 or more weeks of gestational age, all intrapartum deaths at 28 or more weeks of gestational age and neonatal deaths at 34 or more weeks of gestational age. Deaths with major congenital anomalies were excluded. An international audit panel used explicit criteria to review all cases, which were blinded for region. Subjective interpretation was used in cases of events or interventions where explicit criteria did not exist. Suboptimal factors were identified in the antenatal, intrapartum and neonatal periods, and classified as 'maternal/social', due to 'infrastructure/service organization', or due to 'professional care delivery'. The contribution of each suboptimal factor to the fatal outcome was listed and consensus was reached on a final grade using a procedure that included correspondence and plenary meetings. RESULTS: In all regions combined, 90% of all known or estimated cases in the selected categories were included in the audit. In total, 1619 cases of perinatal death were audited. Consensus was reached in 1543 (95%) cases. In 75% of all cases, the grade was based on explicit criteria. In the remaining cases, consensus was reached within subpanels without reference to predefined criteria. There was reasonable to good agreement between and within subpanels, and within panel members. CONCLUSIONS: The international audit procedure proved feasible and led to consistent results. The results that relate to suboptimal care will need to be studied in depth in order to reach conclusions about their implications for assessing the quality of perinatal care in the individual regions.

Vaginal fibroma. Case report.

A case of a vaginal fibroma in a 50-year-old woman is presented. The tumor presented as a solid mass in the upper third of the anterior vaginal wall. Intravenous pyelography (IVP) and cystoscopy excluded any association of the mass with the urinary tract. Surgical excision of the tumor was easily accomplished and histopathological examination established the diagnosis of a fibroid tumor of the vagina.

Risk factors predisposing to fetal loss following a second trimester amniocentesis.

OBJECTIVE: To examine the influence of possible risk factors on fetal loss rate following amniocentesis. DESIGN: Retrospective analysis of case records between 1993 and 1998. SETTING: Fetal medicine unit of a large teaching hospital. POPULATION: One thousand and six women with singleton pregnancies formed the study group. Seven hundred and eight of them had bleeding during the current pregnancy before the procedure. while 298 had a history of three or more first trimester abortions and/or a second trimester miscarriage or termination of pregnancy. Four thousand and twenty-four women who had amniocentesis and had no risk factors served as controls. Both groups were also classified according to maternal age. Group 1:1,610 women aged 20-34 years; Group 2: 2850 women aged 35-39 years; Group 3; 570 women > 40 years. METHODS: Women of both groups underwent a second trimester amniocentesis between 16 and 21 weeks of gestation. Fetal losses following amniocentesis were examined in three time intervals: 1. in the first two weeks after the procedure; 2. up to the 28th week; 3. from the 28th week to term. RESULTS: There was a statistically significant difference in the fetal loss rate between women aged 20-34 years (2.54%) and those > 40 years (5.1%). Women with a history of vaginal bleeding during the current pregnancy had a higher fetal loss rate compared with controls (6.5% vs 2.8%), which corresponds to an odds ratio of 2.4 (95% CI 1.69-3.42). A similar difference was found between the group of women with a history of previous abortions/terminations and the controls (8% vs 2.8%): OR 3.03 (95% Cl 1.92-4.79). CONCLUSIONS: There is a higher risk of fetal loss following amniocentesis in women > 40 years of age compared with those aged 20-34 years. Bleeding in the current pregnancy, a history of three or more first trimester abortions, a second trimester miscarriage or termination of pregnancy seem to be significant predisposing factors for fetal loss after an amniocentesis.

Cervico-isthmic pregnancy: an extremely rare case diagnosed during labour.

This case report describes a cervico-isthmic pregnancy ending in a live vaginal birth at 37+2 weeks' gestation. The case remained undiagnosed throughout pregnancy when after a fairly normal labour a massive haemorrhage occurred. After an unsuccessful effort to control the bleeding conservatively, a total abdominal hysterectomy was carried out. During the operation the diagnosis of cervico-isthmic pregnancy was confirmed, which was in accordance with the pathology report.

False positive serum biochemical screening and subsequent fetal loss in women less than 35 years of age.

OBJECTIVE: To examine the fetal loss rate in women younger than 35 years of age following a false positive serum biochemical screening. DESIGN: Retrospective analysis of case records between 1991 and 1998. SETTING: Fetal medicine unit of a large teaching hospital. POPULATION: Four hundred and fifty-six women with singleton pregnancies and false positive serum biochemical screening for Down's Syndrome (study group). Nine hundred and twelve matched controls with true negative serum biochemical screening (control group). METHODS: Women of both groups had a second trimester serum screening for Down's Syndrome using alpha fetoprotein, human chorionic gonadotrophin (hCG) and unconjugated oestriol (uE3); and they also underwent genetic amniocentesis. RESULTS: The overall fetal loss rate in the study group was 5.3% (24/456), compared with 1.65% (15/912) in the control group RR 3.2, 95% CI 1.7-5.99; P < 0.001). The majority of fetal losses in the study group occurred after 28 weeks, while in the controls this happened between 24 and 28 weeks of gestation. CONCLUSIONS: A false positive serum biochemical screening in women under 35 years of age is associated with a threefold increased risk of subsequent fetal loss. However, most of fetal losses in this group occurred after 28 weeks, indicating that intensive antepartum fetal surveillance could improve the perinatal outcome.

Fetal fibronectin as a predictor of preterm birth.

Preterm delivery remains the leading cause of perinatal mortality and occurs in approximately 7-9% of pregnancies. The main problem for the obstetrician is the inability to detect women at risk from this complication. The presence of fetal fibronectin (fFN) in cervicovaginal secretions has been proposed as a specific predictor of preterm delivery. Immunohistochemical studies suggest that fFN is present in the extracellular matrix of the decidua basalis next to the intervillus space. It has been studied intensively in symptomatic patients and has a positive predictive value of 43-79%. It has also a negative predictive value of 99.7% for birth within 7 days and 93% for delivery before 37 weeks. Similarly, in high-risk asymptomatic women, it has been proved a useful screening tool for the prediction of preterm delivery, yielding a sensitivity of 43-92%, a specificity of 52-93%, a positive predictive value of 43-85% and a negative predictive value of 86-99%. In low-risk asymptomatic women, fFN has a sensitivity of 63-73%, a specificity of 80-98%, a positive predictive value of 13-36% and a negative predictive value of 95-97%. In women presenting with preterm contractions, a negative test may make one withhold potentially dangerous tocolytic therapy. In asymptomatic women this test can identify patients who have a very high risk for early delivery. Women identified as being high-risk can be offered steroid injections in order to improve lung maturity in preterm babies. Additionally, they can be counselled about the signs and symptoms of preterm labour, so that they can seek medical advice before labour is actually established. However, extensive research is still needed, as no clear benefit in preventing preterm birth using this test, has been shown so far.

Local application of methotrexate for ectopic pregnancy with a percutaneous puncturing technique.

Management of ectopic pregnancy remains traditionally surgical. Early detection of unruptured ectopic pregnancies, using both ultrasound techniques and beta-human chorionic gonadotropin (beta-hCG) assays, allows a more conservative treatment. Twenty-six tubal pregnancies, which were managed with local methotrexate (MTX) injection, are presented. A single dose of 10-12.5 mg of MTX was percutaneously injected into the gestational sac under abdominal sonographic control. Complete resolution was obtained in all our patients. Four of them required a second percutaneous administration 4 days after the first one. Negligible serum beta-hCG levels (< 10 mIU/ml) were reached within 42 days after treatment. No systemic side effects were observed. Local administration of MTX under abdominal sonographic control seems to be an effective alternative for the treatment of ectopic pregnancy. The main potential advantages of the method are (1) a greater antitrophoblastic effect; (2) a shorter treatment period; (3) reduced dosage, and (4) absence of side effects.

Predictive value of amniotic fluid and fetal blood cultures in pregnancy outcome in preterm prelabour rupture of membranes.

We carried out a comprehensive prospective study of 26 pregnancies complicated by preterm rupture of the membranes. Microbiological assessment included cultures for aerobic and anaerobic bacteria, Mycoplasmas, Chlamydia, Trichomonas and fungi from: high vaginal and cervical swabs, maternal blood and urine, amniotic fluid and fetal blood on admission and finally, placenta and umbilical cord = after delivery. The group with positive cultures (n 16), was compared with the group with negative cultures = (n 10) in terms of gestational age at labour, latent phase after membrane rupture and fetal and neonatal morbidity and mortality. All patients with positive cultures delivered before 32 weeks and their neonates had evidence of infection. Three intrauterine deaths occurred in this group and 12/13 (86%) of the live neonates were admitted to the neonatal intensive care unit. The 10 (38%) patients of the group with negative cultures delivered after 32 weeks, had no perinatal deaths, and only two were admitted to neonatal intensive care. The median latent phase differed between these two groups (4.5 vs. 53.5 days, P 0.01), as did the median gestational age at labour (28 vs. 36 4 weeks, P 0.01). A positive amniotic fluid or fetal blood culture in the clinical setting of preterm rupture of the membranes indicates labour onset within a few days. Intrauterine infection with fetal sepsis is accompanied by high neonatal infectious morbidity (100%) and mortality (30%).

Circulating levels of immunoreactive parathyroid hormone-related protein and intact parathyroid hormone in human fetuses and newborns.

Undetectable or extremely low levels of circulating immunoreactive parathyroid hormone (PTH) have been reported in human newborns while PTH bioactivity was high. This prompted the hypothesis that the fetal calcemic hormone might be PTH-related protein. The purpose of this study was to measure circulating immunoreactive PTH-related protein in human fetuses and newborns in order to investigate this hypothesis. Parathyroid hormone-related protein (PTHrP(1-86) and intact PTH were measured using two-site immunoradiometric assays in plasma obtained by cordocentesis from 23 fetuses (19-33 weeks of gestation), from 17 newborns at term (38-41 weeks), from their mothers and from 22 normal women of reproductive age. Plasma PTHrP was detectable in all but one of the fetuses and newborns and in all the mothers and the controls. The mean level was similar among fetuses (19-33 weeks) (0.43 +/- 0.18 pmol/l), newborns (0.48 +/- 0.12), mothers (0.48 +/- 0.14) and normal controls (0.46 +/- 0.09). Plasma PTH was found to be significantly higher in fetuses at midgestation (1.0 +/- 0.99 pmol/l) than in the newborns (0.22 +/- 0.21) (p < 0.0025); maternal PTH was significantly higher compared to fetal level at mid-gestation (2.1 +/- 1.0, p < 0.01) as well as at term (2.69 +/- 1.40, p < 0.001). In the control women PTH was 3.07 +/- 1.25 pmol/l. These results showed that plasma amino-terminal PTHrP-(1-86) is detectable during the second half of human fetal life and its level remains unchanged during this period of time, in contrast to changing levels of fetal plasma PTH. The relatively low PTHrP-(1-86) level that we found in the newborns is not responsible for the high PTH-like bioactivity found by some investigators in cord blood at term.

Cardiocentesis: an alternative method of fetal blood sampling for the prenatal diagnosis of hemoglobinopathies.

One hundred fifty-eight cases are reported of fetal cardiocentesis during the second trimester for the prenatal diagnosis of hemoglobinopathies. In all cases, fetal blood sampling by funipuncture was technically impossible or unsuccessful. There were nine fetal deaths possibly related to the procedure, for a total fetal loss rate of 6.5%. If one fetal loss that occurred 46 days after the procedure is excluded, the total procedure-related fetal loss rate is 5.6%. No cases of maternal chorioamnionitis, fetal cardiac trauma, or hemopericardium were encountered among the living infants. We conclude that cardiocentesis should be offered in highly selective cases when funipuncture is not technically feasible. In experienced hands, the procedure has a fetal loss rate of 6.5% with no morbidity among the survivors.