Spontaneous preterm labour and delivery at under 34 weeks' gestation.

The management and outcome of 242 infants delivered between 26 and 34 weeks'' gestation in an obstetrical and neonatal regional referral centre as a result of spontaneous preterm labour were recorded prospectively. Results of the survey show that the decision to intervene and delay delivery will depend on the availability of neonatal intensive care facilities. Infants likely to require intensive neonatal care should be transferred in utero to a centre with these facilities. The use of steroids reduces the mortality of preterm infants. The maximum effect occurs between 30 and 32 weeks'' gestation, and there is no benefit after 34 weeks. If the weight is over 1500 g the mode of delivery of the preterm infant presenting by the breech does not influence outcome; if under 1500 g a caesarean section improves survival over those infants born by vaginal breech delivery.     

Increased mortality of preterm infants transferred between tertiary perinatal centres.

Over 18 months almost one quarter of infants born before 30 weeks'' gestation in a tertiary perinatal centre who required intensive care had to be transferred to other tertiary centres because intensive care facilities were fully occupied. When infants with lethal congenital malformations were excluded half of the 34 infants who were transferred died; this was twice the mortality (24%) in the 111 infants remaining. The difference between the groups was significant (relative odds = 3.1) and remained so after adjustment for any discrepancies in gestational age (relative odds = 4.0). After adjustment for potential confounding variables by logistic function regression the risk of dying for those transferred remained significantly higher than that for infants who remained (relative odds = 4.6, 95% confidence interval 1.8 to 12.1). As the requirement for neonatal intensive care is episodic and unpredictable more flexibility has to be built into the perinatal health care system to enable preterm infants delivered in tertiary perinatal centres to be cared for where they are born.     

Regional neonatal intensive care: bias and benefit.

Among very low birthweight infants born to residents of Merseyside in 1979-81 those booked at or transferred in utero to the regional unit were more likely to survive than those born elsewhere in the region. A study was carried out to determine whether the increased survival rate was attributable to better care or differences in the babies treated at the unit, or both. Four subpopulations were defined by district of maternal residence to obtain fairly comparable samples. Survival to 2 years increased as proportions treated at the regional unit increased, this "dose-response" effect being most pronounced among the smallest infants. Despite less favourable social state infants from the district housing the regional unit were apparently in the best condition at birth; had been managed most actively before, at, and after birth; and were the most likely to survive. This increased survival, however, was associated with a marginally significant increase in prevalence of major impairments. These data underline the need for routine surveillance of large representative samples of low birthweight survivors.     

Cancer mortality following in utero exposure among offspring of female mayak worker cohort members

Little is known about long-term cancer risks following in utero radiation exposure. We evaluated the association between in utero radiation exposure and risk of solid cancer and leukemia mortality among 8,000 offspring, born from 1948-1988, of female workers at the Mayak Nuclear Facility in Ozyorsk, Russia. Mother's cumulative gamma radiation uterine dose during pregnancy served as a surrogate for fetal dose. We used Poisson regression methods to estimate relative risks (RRs) and 95% confidence intervals (CIs) of solid cancer and leukemia mortality associated with in utero radiation exposure and to quantify excess relative risks (ERRs) as a function of dose. Using currently available dosimetry information, 3,226 (40%) offspring were exposed in utero (mean dose = 54.5 mGy). Based on 75 deaths from solid cancers (28 exposed) and 12 (6 exposed) deaths from leukemia, in utero exposure status was not significantly associated with solid cancer: RR = 0.94, 95% CI 0.58 to 1.49; ERR/Gy = -0.1 (95% CI < -0.1 to 4.1), or leukemia mortality; RR = 1.65, 95% CI 0.52 to 5.27; ERR/Gy = -0.8 (95% CI < -0.8 to 46.9). These initial results provide no evidence that low-dose gamma in utero radiation exposure increases solid cancer or leukemia mortality risk, but the data are not inconsistent with such an increase. As the offspring cohort is relatively young, subsequent analyses based on larger case numbers are expected to provide more precise estimates of adult cancer mortality risk following in utero exposure to ionizing radiation.     

Survival of bisected rabbit morulae transferred to synchronous and asynchronous recipients

The rabbit was used as a model to test the concept that temporal asynchrony is required to establish physiological synchrony when embryos are bisected to produce demiembryos. In preliminary studies with intact embryos it was confirmed that embryos harvested on days 2, 3, 4, or 5 (day 0 = day of breeding) can be transferred with +/- 1 day of asynchrony to the uteri of recipient rabbits. Three experiments were conducted with bisected embryos. In experiment 1, 192 bisected and 194 control day 3 embryos were transferred to uteri of day 2, 2.5, and 3 recipients (ovulated 0, 12, and 24 h after the donors), with 14% of the bisected and 39% of the intact embryos (P less than .05) resulting in young. Only 4% (2/48) of the day 3 bisected embryos vs. 39% (P less than .05) of the intact day 3 embryos survived in the uteri of day 2 recipients. In experiment 2, day 3 bisected and intact embryos were transferred to the oviducts of day 3, 3.5, or 4 recipients, the speculation being that the oviduct might provide a more neutral environment than the uterus. However, embryo survival was very low, except for the intact embryos transferred to synchronized recipients (42% young born). In experiment 3, 150 intact and 162 (81 pairs) bisected day 3 embryos collected from uteri were transferred to uteri of day 2.5, 3.0, and 3.5 recipient does. Significantly more pregnancies (100% vs. 47%, P less than .01) and young born (56% vs. 19%, P less than .01) resulted from intact embryos than from bisected embryos, irrespective of the uterine age.(ABSTRACT TRUNCATED AT 250 WORDS)     

Short term outcome in babies refused perinatal intensive care.

OBJECTIVE--To compare the mortality in babies refused admission to a regional perinatal centre with that in babies accepted for intensive care in the centre. DESIGN--Retrospective study with group comparison. SETTING--Based at the Royal Maternity Hospital, Belfast, with follow up of patients in all obstetric units in Northern Ireland. PATIENTS--Requests for transfer of 675 babies to the regional perinatal centre (prenatally and postnatally) were made from hospitals in Northern Ireland between January 1984 and December 1986. In all, 343 babies were refused admission to the centre, and complete data were available for 332 of them. These babies were either admitted to other neonatal intensive care units (261 babies) or remained in hospitals with only special care cots (71 babies). MAIN OUTCOME MEASURE--Short term mortality. RESULTS--Seventy of the 332 babies refused admission to the centre died compared with 51 of the 333 who were admitted. Multivariate analysis based on a logistic model showed a non-significant increase in mortality among babies treated in other intensive care units compared with babies treated in the centre (relative odds 1.2; 95% confidence interval 0.7 to 1.9). The increase in mortality in babies who remained in a special care baby unit, however, was significant (3.5; 1.7 to 7.0). This increase was particularly significant in babies born at less than or equal to 32 weeks'' gestation and who weighed less than 1500 g (8.4; 2.5 to 28.1). CONCLUSIONS--The results of the study confirm the benefits of neonatal intensive care and its particular value in improving survival in babies of low birth weight. As the babies were refused admission to the regional perinatal centre because intensive care cots were not available this deficiency should be corrected.     

Perinatal transmission of SHIV-SF162P3 in Macaca nemestrina

We developed a SHIV/macaque model of transmission from infected dams to their infants. Ten pregnant dams were infected intravenously with 100 MID(50) of macaque-titered SHIV-SF162P3 during the second trimester. Nine infants were born; the seven surviving beyond day of birth suckled for 6 months. Four of nine infants were infected (transmission rate = 44.4%), with one infection in utero, and three intrapartum and/or immediately post-birth via suckling. Varying levels of binding and neutralizing antibodies were transplacentally transferred to infants. Passive antibodies were detected in plasma on the day of birth and persisted for 5 weeks. Infants infected at or after birth controlled acute and post-acute viremia. Exposure to maternal SHIV-SF162P3 during birth and suckling in the presence of autologous maternal neutralizing antibodies may have affected transmission or pathogenesis in the infants. This transmission model can allow investigation of key parameters involved in perinatal transmission of HIV.     

Current practice in transferring critically ill patients among hospitals in the west of Scotland.

OBJECTIVE--To identify the requirements of an interhospital transfer service for critically ill patients. DESIGN--Retrospective survey of the current functions of a specialist interhospital transfer team from data collected at the time of transfer and from records of intensive care unit. SETTING--Mobile intensive care unit based at a tertiary referral centre, which serves the west of Scotland. PATIENTS--All critically ill patients (378) transferred between hospitals by the unit from 1986 to 1988. RESULTS--365 Patients were transferred by road and 13 by air. There was a wide variation in age (range 6 weeks to 87 years), diagnosis, reason for transfer, support required, and distance travelled. Most patients (232) were transferred for respiratory or cardiovascular support; 100 were trauma cases. 300 Patients (79%) were mechanically ventilated during transfer. No patient died in transit, although the eventual mortality was 28% (105 patients). Mortality was significantly higher in patients transferred from hospitals with intensive care units than from those without (38% (125 patients) v 23% (253); p less than 0.005). IMPLICATIONS--Safe interhospital transfer of critically ill patients is feasible; the high eventual mortality in some patient groups emphasises the need for accurate prediction of outcome if inappropriate transfer is to be avoided. The findings may help in organising secondary transfer services in future.     

Does HIV status influence the outcome of patients admitted to a surgical intensive care unit? A prospective double blind study.

OBJECTIVES: (a) To assess the impact of HIV status (HIV negative, HIV positive, AIDS) on the outcome of patients admitted to intensive care units for diseases unrelated to HIV; (b) to decide whether a positive test result for HIV should be a criterion for excluding patients from intensive care for diseases unrelated to HIV. DESIGN: A prospective double blind study of all admissions over six months. HIV status was determined in all patients by enzyme linked immunosorbent assay (ELISA), immunofluorescence assay, western blotting, and flow cytometry. The ethics committee considered the clinical implications of the study important enough to waive patients'' right to informed consent. Staff and patients were blinded to HIV results. On discharge patients could be advised of their HIV status if they wished. SETTING: A 16 bed surgical intensive care unit. SUBJECTS: All 267 men and 135 women admitted to the unit during the study period. INTERVENTIONS: None. MAIN OUTCOME MEASURES: APACHE II score (acute physiological, age, and chronic health evaluation), organ failure, septic shock, durations of intensive care unit and hospital stay, and intensive care unit and hospital mortality. RESULTS: No patient had AIDS. 52 patients were tested positive for HIV and 350 patients were tested negative. The two groups were similar in sex distribution but differed significantly in age, incidence of organ failure (37 (71%) v 171 (49%) patients), and incidence of septic shock (20 (38%) v 54 (15%)). After adjustment for age there were no differences in intensive care unit or hospital mortality or in the durations of stay in the intensive care unit or hospital. CONCLUSIONS: Morbidity was higher in HIV positive patients but there was no difference in mortality. In this patient population a positive HIV test result should not be a criterion for excluding a patient from intensive care.     

Effectiveness of neonatal transport.

The condition of 259 infants transferred to the neonatal intensive care unit (NICU) of the Montreal Children''s Hospital from Oct. 1, 1974 to Mar. 31, 1975 was evaluated. Their transport was provided by personnel and equipment from the Montreal Children''s Hospital. When the transport team arrived at the referring hospital hypothermia (temperature of less than 36 degrees C) was present in 25.2% of the 163 infants for whom complete temperature measurements were available. Most (77.3%) of the infants were warmed during transport and only 3.1% arrived at the NICU with a temperature of less than 35 degrees C. The mortality was significantly higher in babies of all birth weight groups whose core temperature had been below the optimal temperature for survival (36 to 37 degrees C). It appears that the use of appropriate equipment and trained personnel can reduce the incidence of hypothermia and therefore the mortality in infants requiring transfer.     

Maternal morbidity associated with in utero transfer.

OBJECTIVE--To determine the extent of maternal morbidity associated with in utero transfer. DESIGN--Retrospective study of 190 consecutive cases over two years. SETTING--Liverpool Maternity Hospital. PATIENTS--190 Pregnant women were transferred to the hospital under the in utero transfer arrangements from district general hospitals both within and outside the Mersey region. The women admitted were divided into two categories: those in threatened or established uncomplicated preterm labour and those who may or may not have been in threatened or established preterm labour but who had coexisting complicating factors affecting the mother or fetus, or both. INTERVENTIONS--Planned delivery of the fetus if indicated and arrangements for appropriate postpartum care of the mother. MAIN OUTCOME MEASURE--Assessment of the progress of labour and, if appropriate, resuscitation of the mother. RESULTS--Women who were transferred with no coexisting disease (124) had relatively uncomplicated deliveries whereas those transferred with coexisting diseases (66) exhibited considerable morbidity and 17 of these required prolonged intensive monitoring after delivery. CONCLUSIONS--In utero transfer in healthy mothers may have benefits for babies born very prematurely. If mothers have coexisting disease, however, the desirability of transfer should be reviewed urgently in the light of the considerable maternal morbidity associated with these problems. In these cases transfer may introduce an additional hazard.     

Referral of mothers and infants for intensive care.

During 1975-7, 96 mothers were referred to University College Hospital for delivery from 39 other hospitals because their pregnancies were considered to be at very high risk. One hundred of the 111 infants born to the 96 mothers weighed 2500 g or less and 60 weighed 1500 g or less. A high proportion of the infants developed serious illnesses necessitating intensive care. The birth-weight-specific neonatal mortality rates of the infants were much lower than those of infants born in England and Wales as a whole and were also lower than those of the 370 infants transported to this hospital for intensive care after delivery elsewhere. Whenever possible mothers with very high-risk pregnancies should be referred for delivery to centres with full facilities for the intensive care of the mother, fetus, and newborn infant.     

Prognosis for infants with idiopathic respiratory distress syndrome.

Infants with the idiopathic respiratory distress syndrome admitted to the intensive care unit during January 1972 to September 1974 were reviewed. The overall mortality rate for infants whose birth weight was 1000 g or more was under 10%, and for those who established spontaneous respiration after birth it was less than 5%. The hyperoxia test was not a useful guide to prognosis. It was possible on the basis of the infants'' ability to establish spontaneous ventilation after birth to divide them into two groups. In those who established adequate ventilation the mortality rate was 4-5%; in those who did not it was 57%. This test should be generally applied, since not only does it give an immediate guide to the severity of the disease, which is better than that provided by birth weight, gestational age, or the hyperoxia test, but it may be applied to infants born in and outside a hospital providing neonatal intensive care. Improvement in the outlook for infants with a bad prognosis will be achieved only by improvements in perinatal care designed to minimize severe intrapartum asphyxia in infants of low birth weight.     

Retrospective study of maternal HIV-1 and HIV-2 infections and child survival in Abidjan,C?te d'Ivoire.

OBJECTIVES--To compare the effects of maternal HIV-1 and HIV-2 infections on outcome of pregnancy, infant mortality, and child survival, and to measure serological concordance between mothers and children. DESIGN--Retrospective cohort study with cross sectional study of concordance for HIV antibodies. SETTING--Hospital, tuberculosis clinic, and maternal and child health centre in Abidjan, Côte d''Ivoire, west Africa. SUBJECTS--986 women who had had a total of 2758 pregnancies since 1980. The last born children of 194 of these women. MAIN OUTCOME MEASURES--Pregnancy outcomes; mortality for all children born since 1980; and outcome for last born children. Serological concordance between mothers and last born children. RESULTS--Women with HIV-1 and HIV-2 infections had higher rates of spontaneous abortion and stillbirth than uninfected women (86/769 in HIV-1 positive women, 48/421 in HIV-2 positive, 31/234 in dually reactive, and 96/1131 in uninfected). Compared with children born to uninfected mothers (mortality 10.3%), greater proportions of children of HIV-1 positive (20.6%) and dually reactive (20.3%) mothers had died; mortality in children of HIV-2 infected women (13.1%) was not significantly increased. Infant mortalities for the last born children of HIV-1 positive, dually reactive, HIV-2 positive, and seronegative women were, respectively, 133, 82, 32, and 40 per 1000 live births. Nine of 77 last born children of HIV-1 positive mothers were concordantly seropositive compared with none of 21 children of HIV-2 infected mothers. CONCLUSIONS--Maternal HIV-2 infection has less influence on child survival than infection with HIV-1, probably because of a lower vertical transmission rate.     

Perinatal mortality rates in isolated general practitioner maternity units.

OBJECTIVE--To determine the perinatal mortality rate among normally formed, singleton babies with birth weights greater than or equal to 2500 g in Bath health district based on the intended place of delivery at the time of onset of labour or at the time of diagnosis of intrauterine death. DESIGN--The numbers of live births and stillbirths were collected monthly returns from the maternity units concerned. Deaths of infants aged less than or equal to 1 week were collected in the same returns. The intended place of delivery was confirmed at the monthly perinatal mortality meeting, during which maternal and fetal factors were discussed. SETTING--A rural health district of 400,000 population where one third of all deliveries occurred in seven isolated general practitioner maternity units, 8% in the integrated general practitioner unit, and the remainder in the consultant unit. SUBJECTS--All babies of women whose deliveries were booked in the district before the onset of labour or the diagnosis of intrauterine death, excluding twins, babies with lethal congenital malformations, and those less than 2500 g. MAIN OUTCOME MEASURES--Outcome of all deliveries and parity of mothers. RESULTS--14,415 Deliveries were analysed. The perinatal mortality rate was 2.8/1000 births in the consultant unit (7950 deliveries), 4.8 in the isolated general practitioner units (5237 deliveries), and zero in the integrated general practitioner unit (1228 deliveries). Perinatal deaths attributable to asphyxia were more common in the isolated general practitioner units (1.5 per 1000) than the consultant unit (0.6 per 1000). The perinatal mortality rate among babies born to nulliparous women was 3.2/1000 births in the consultant unit and 5.7 in the isolated general practitioner units; for those born to multigravid women it was 2.4 and 4.2 respectively. CONCLUSIONS--The outcome of delivery was not influenced by parity. Both antenatal and intrapartum care were responsible for the higher perinatal mortality rate in the isolated general practitioner units. The integrated unit, which shared midwifery staff with the consultant unit, seemed to work well. Analysis by intended place of delivery at the time of onset of labour or diagnosis of intrauterine death suggested that the care given in isolated units needs to be improved, perhaps by better training of general practitioners and consultant supervision of antenatal care.     

Midwife managed delivery unit: a randomised controlled comparison with consultant led care.

OBJECTIVE--To examine whether intrapartum care and delivery of low risk women in a midwife managed delivery unit differs from that in a consultant led labour ward. DESIGN--Pragmatic randomised controlled trial. Subjects were randomised in a 2:1 ratio between the midwives unit and the labour ward. SETTING--Aberdeen Maternity Hospital, Grampian. SUBJECTS--2844 low risk women, as defined by existing booking criteria for general practitioner units in Grampian. 1900 women were randomised to the midwives unit and 944 to the labour ward. MAIN OUTCOME MEASURES--Maternal and perinatal morbidity. RESULTS--Of the women randomised to the midwives unit, 647 (34%) were transferred to the labour ward antepartum, 303 (16%) were transferred intrapartum, and 80 (4%) were lost to follow up. 870 women (46%) were delivered in the midwives unit. Primigravid women (255/596, 43%) were significantly more likely to be transferred intrapartum than multi-gravid women (48/577, 8%). Significant differences between the midwives unit and labour ward were found in monitoring, fetal distress, analgesia, mobility, and use of episiotomy. There were no significant differences in mode of delivery or fetal outcome. CONCLUSIONS--Midwife managed intrapartum care for low risk women results in more mobility and less intervention with no increase in neonatal morbidity. However, the high rate of transfer shows that antenatal criteria are unable to determine who will remain at low risk throughout pregnancy and labour.     

Predicting child abuse: signs of bonding failure in the maternity hospital.

Fifty children referred to the Park Hospital because of actual or threatened abuse were compared with 50 controls born at the same maternity hospital. Five factors were significantly more common in the abused group than among their controls: (a) mother aged under 20 at birth of first child, (b) evidence of emotional disturbance, (c) referral of family to hospital social worker, (d) baby''s admission to special care baby unit, (e) recorded concern over the mother''s ability to care for child. Thirty-five of the abused group had two or more of these factors compared with only five of the control group. As these data were collected from information recorded routinely at the maternity hospital, it is possible to identify most abusing families when the child is born. Such identification must lead to a comprehensive assessment of each case followed by constructive preventive action.     

Perinatal characteristics in relation to incidence of and mortality from prostate cancer.

OBJECTIVE--To test the hypothesis that factors causing morbidity and mortality from prostate cancer may operate in utero. DESIGN--Matched case-control study of singleton men born between 1874 and 1946 at one hospital. SETTING--Uppsala University Hospital. SUBJECTS--250 patients with prostate cancer and 691 controls, including 80 patients who died from prostate cancer and their 196 matched controls. MAIN OUTCOME MEASURES--Mother''s age at menarche, parity, pre-eclampsia or eclampsia before delivery, age at delivery and socioeconomic status; case or control''s birth length and weight, placental weight, prematurity derived from gestational age, and presence of jaundice. RESULTS--Both pre-eclampsia (odds ratio 0, 95% confidence interval 0 to 0.71) and prematurity (0.31, 0.09 to 1.04) were inversely associated with incidence of prostate cancer. Among subjects born full term, placental weight, birth weight, and ponderal index (weight/height 3) showed non-significant positive associations with prostate cancer incidence, and stronger associations with mortality. CONCLUSION--Prenatal exposures that are likely correlates of pregnancy hormones and other growth factors are important in prostate carcinogenesis and influence the natural course as well as the occurrence of this cancer.     

Case--control study of counselling against neonatal circumcision.

After two serious complications had alerted physicians to the potential risks of routine neonatal circumcision, the circumcision rate in a regional general hospital decreased significantly (p less than 0.001), from approximately 40% to 20%, settling at the level claimed to prevail when physicians oppose circumcision. Following this decrease 219 consecutive pregnancies resulting in male infants were prospectively studied in order to identify factors associated with insistence on circumcision. Factors significantly associated with circumcision were the existence of an older brother (p less than 0.001), especially if circumcised (p less than 0.001), and delivery of prenatal care by an obstetrician rather than a general practitioner (p less than 0.05). Factors significantly associated with no circumcision were the fact that this infant was the first male born in the family (p = 0.001), delivery of prenatal and infant care by the same general practitioner (p less than 0.05) and a maternal age of 20 years or less (p less than 0.02). The circumcision status of the father, the marital status of the mother, the mother''s intention to breast-feed, attendance of a primigravida at prenatal classes, delivery of infant care by a pediatrician and socioeconomic status did not appear to influence whether circumcision was performed. These data may assist physicians in understanding the potential effectiveness and limitations of counselling against circumcision.