Using three-dimensional ultrasound in predicting complex gastroschisis:A longitudinal, prospective, multicenter cohort study

Objective: To determine whether complex gastroschisis (ie, intestinal atresia, perforation, necrosis, or volvulus) can prenatally be distinguished from simple gastroschisis by fetal stomach volume and stomach-bladder distance, using three-dimensional (3D) ultrasound. Methods: This multicenter prospective cohort study was conducted in the Netherlands between 2010 and 2015. Of seven university medical centers, we included the four centers that performed longitudinal 3D ultrasound measurements at a regular basis. We calculated stomach volumes (n = 223) using Sonography-based Automated Volume Count. The shortest stomach-bladder distance (n = 241) was determined using multiplanar visualization of the volume datasets. We used linear mixed modelling to evaluate the effect of gestational age and type of gastroschisis (simple or complex) on fetal stomach volume and stomach-bladder distance. Results: We included 79 affected fetuses. Sixty-six (84%) had been assessed with 3D ultrasound at least once; 64 of these 66 were liveborn, nine (14%) had complex gastroschisis. With advancing gestational age, stomach volume significantly increased, and stomach-bladder distance decreased (both P <.001). The developmental changes did not differ significantly between fetuses with simple and complex gastroschisis, neither for fetal stomach volume (P =.85), nor for stomach bladder distance (P =.78). Conclusion: Fetal stomach volume and stomach-bladder distance, measured during pregnancy using 3D ultrasonography, do not predict complex gastroschisis

Ultrasound markers for prediction of complex gastroschisis and adverse outcome: longitudinal prospective nationwide cohort study

Objectives: To identify antenatal ultrasound markers that can differentiate between simple and complex gastroschisis and assess their predictive value. Methods: This was a prospective nationwide study of pregnancies with isolated fetal gastroschisis that underwent serial longitudinal ultrasound examination at regular specified intervals between 20 and 37 weeks' gestation. The primary outcome was simple or complex (i.e. involving bowel atresia, volvulus, perforation or necrosis) gastroschisis at birth. Fetal biometry (abdominal circumference and estimated fetal weight), the occurrence of polyhydramnios, intra- and extra-abdominal bowel diameters and the pulsatility index (PI) of the superior mesenteric artery (SMA) were assessed. Linear mixed modeling was used to compare the individual trajectories of cases with simple and those with complex gastroschisis, and logistic regression analysis was used to estimate the strength of association between the ultrasound parameters and outcome. Results: Of 104 pregnancies with isolated fetal gastroschisis included, four ended in intrauterine death. Eighty-one (81%) liveborn infants with simple and 19 (19%) with complex gastroschisis were included in the analysis. We found no relationship between fetal biometric variables and complex gastroschisis. The SMA-PI was significantly lower in fetuses with gastroschisis than in healthy controls, but did not differentiate between simple and complex gastroschisis. Both intra- and extra-abdominal bowel diameters were larger in cases with complex, compared to those with simple, gastroschisis (P < 0.001 and P < 0.005, respectively). The presence of intra-abdominal bowel diameter ≥ 97.7th percentile on at least three occasions, not necessarily on successive examinations, was associated with an increased risk of the fetus having complex gastroschisis (relative risk, 1.56 (95% CI, 1.02–2.10); P = 0.006; positive predictive value, 50.0%; negative predictive value, 81.4%). Conclusions: This large prospective longitudinal study found that intra-abdominal bowel dilatation when present repeatedly during fetal development can differentiate between simple and complex gastroschisis; however, the positive predictive value is low, and therefore the clinical usefulness of this marker is limited

Comparison of single and repeated antenatal corticosteroid therapy to prevent neonatal death and morbidity in the preterm infant

INTRODUCTION: In the case of threatened preterm delivery, repeat administration of antenatal corticosteroids is a common practice in women who have not delivered 7-14 days after the first course of corticosteroids. However, the benefits of this policy as compared to single-course administration have not been proven. AIM: Our purpose was to compare neonatal death and morbidity after repeat antenatal courses of corticosteroids with neonatal death and morbidity after a single course. METHODS: We performed a cohort study with matched controls. Neonates treated with repeat antenatal courses of corticosteroids were matched with neonates treated with a single course. Matching criteria were sex, single or multiple gestation, route of delivery, gestational age at delivery and year of birth. Intrauterine growth-restricted infants were matched separately. We excluded neonates with congenital malformation and neonates with an unknown number of antenatal corticosteriod courses. Outcome measures were the incidences of neonatal death, respiratory distress syndrome, intraventricular haemorrhage and necrotizing enterocolitis. RESULTS: From the neonates treated with two or three courses of antenatal corticosteroids, 56 appropriate grown neonates and 24 intrauterine growth-restricted neonates could be matched. The incidences of neonatal death, respiratory distress syndrome, intraventricular haemorrhage and necrotizing enterocolitis did not show statistically significant differences after single and repeat courses of corticosteroids. Appropriate grown and intrauterine growth-restricted neonates showed the same results. CONCLUSION: From our study, it can be concluded that in preterm neonates, repetition of antenatal corticosteroids seems not to improve neonatal outcom

Regional perinatal mortality differences in the Netherlands; care is the question

ABSTRACT: BACKGROUND: Perinatal mortality is an important indicator of health. European comparisons of perinatal mortality show an unfavourable position for the Netherlands. Our objective was to study regional variation in perinatal mortality within the Netherlands and to identify possible explanatory factors for the found differences. METHODS: Our study population comprised of all singleton births (904,003) derived from the Netherlands Perinatal Registry for the period 2000-2004. Perinatal mortality including stillbirth from 22+0 weeks gestation and early neonatal death (0-6 days) was our main outcome measure. Differences in perinatal mortality were calculated between 4 distinct geographical regions North-East-South-West. We tried to explain regional differences by adjustment for the demographic factors maternal age, parity and ethnicity and by socio-economic status and urbanisation degree using logistic modelling. In addition, regional differences in mode of delivery and risk selection were analysed as health care factors. Finally, perinatal mortality was analysed among five distinct clinical risk groups based on the mediating risk factors gestational age and congenital anomalies. RESULTS: Overall perinatal mortality was 10.1 per 1,000 total births over the period 2000-2004. Perinatal mortality was elevated in the northern region (11.2 per 1,000 total births). Perinatal mortality in the eastern, western and southern region was 10.2, 10.1 and 9.6 per 1,000 total births respectively. Adjustment for demographic factors increased the perinatal mortality risk in the northern region (odds ratio 1.20, 95% CI 1.12-1.28, compared to reference western region), subsequent adjustment for socio-economic status and urbanisation explained a small part of the elevated risk (odds ratio 1.11, 95% CI 1.03-1.20). Risk group analysis showed that regional differences were absent among very preterm births (22+0 - 25+6 weeks gestation) and most prominent among births from 32+0 gestation weeks onwards and among children with severe congenital anomalies. Among term births ([greater than or equal to] 37+0 weeks) regional mortality differences were largest for births in women transferred from low to high risk during delivery. CONCLUSION: Regional differences in perinatal mortality exist in the Netherlands. These differences could not be explained by demographic or socio-economic factors, however clinical risk group analysis showed indications for a role of health care factor

Audit van aterme perinatale sterfte in Nederland. Een landelijk cohortonderzoek over de periode 2010-2012

Investigation of the implementation and results of the national term perinatal mortality audit. Population-based cohort study. Perinatal audits were carried out in all 90 Dutch hospitals with obstetric departments together with the surrounding midwifery practices. These audits involved cases of term perinatal mortality. Various registries were used to collect data relating to audit participation, perinatal death classification, shortcomings in care (substandard factors; SSF) and their relation to death, recommendations for quality improvement in care and antepartum risk assessment. 1,102 term perinatal deaths occurred between 2010 and 2012. 645 audit sessions took place with an average of 31 participants per session. Data were recorded for 943 cases of term perinatal death (86%), and audit results for 707 (64%). In 53% of the cases at least one SSF was identified. Non-compliance with guidelines (35%) and deviation from conventional professional care (41%) were the most common. The percentage of cases of mortality in which there was a probable relation between SSFs and death decreased from 10% (n = 23) in 2010 to 5% (n = 10) in 2012 (p = 0.060). Term perinatal mortality decreased from 2.3 to 2.0 per 1000 births (p <0.001). Possibilities for improvement were identified in the organisation of care (35%), compliance with guidelines or conventional care (19%) and in better documentation (15%). The perinatal audit was implemented over a short period of time. Term perinatal mortality in the Netherlands decreased during the period in which this study took plac

Term perinatal mortality audit in the Netherlands 2010-2012: a population-based cohort study

To assess the implementation and first results of a term perinatal internal audit by a standardised method. Population-based cohort study. All 90 Dutch hospitals with obstetric/paediatric departments linked to community practices of midwives, general practitioners in their attachment areas, organised in perinatal cooperation groups (PCG). The population consisted of 943 registered term perinatal deaths occurring in 2010-2012 with detailed information, including 707 cases with completed audit results. Participation in the audit, perinatal death classification, identification of substandard factors (SSF), SSF in relation to death, conclusive recommendations for quality improvement in perinatal care and antepartum risk selection at the start of labour. After the introduction of the perinatal audit in 2010, all PCGs participated. They organised 645 audit sessions, with an average of 31 healthcare professionals per session. Of all 1102 term perinatal deaths (2.3/1000) data were registered for 86% (943) and standardised anonymised audit results for 64% (707). In 53% of the cases at least one SSF was identified. Non-compliance to guidelines (35%) and deviation from usual professional care (41%) were the most frequent SSF. There was a (very) probable relation between the SSF and perinatal death for 8% of all cases. This declined over the years: from 10% (n=23) in 2010 to 5% (n=10) in 2012 (p=0.060). Simultaneously term perinatal mortality decreased from 2.3 to 2.0/1000 births (p <0.00001). Possibilities for improvement were identified in the organisation of care (35%), guidelines or usual care (19%) and in documentation (15%). More pregnancies were antepartum selected as high risk, 70% in 2010 and 84% in 2012 (p=0.0001). The perinatal audit is implemented nationwide in all obstetrical units in the Netherlands in a short time period. It is possible that the audit contributed to the decrease in term perinatal mortalit

Figure 2

<p><b>A.</b> Development of urinary SAA levels in patients undergoing surgery 2 or more days after diagnosis. D: day of diagnosis, S-2∶2 days prior to surgery; S-1∶1 day prior to surgery. A cut-off value of 27.8 ng/ml is depicted by the dotted line. <b>B.</b> Development of platelet levels in patients undergoing surgery 2 or more days after diagnosis. D: day of diagnosis, S-2∶2 days prior to surgery; S-1∶1 day prior to surgery.</p

Test characteristics of urinary SAA and platelet count.

<p>*Cut-off line described by the linear function: [platelet count (10⁹ cells/l)] –25 • [SAA (ng/ml)] <159.3.</p><p>D = at diagnosis.</p><p>D/S-1 = at diagnosis (D) of neonates with moderate NEC, who were operated on the same day or who died; pooled with levels at one day prior to surgery (S-1) in neonates who were operated after the day of diagnosis.</p><p>LR+ = positive likelihood ratio.</p><p>LR− = negative likelihood ratio.</p><p>AUC = area under the curve.</p><p>CI = Confidence interval.</p

Control values of urinary and fecal marker.

<p>*No samples except two above lower detection limit.</p><p>**No samples except one above lower detection limit.</p