National perinatal audit, a feasible initiative for the Netherlands!? A validation study

Objective. To explore the feasibility of a national perinatal audit organization. Design. Validation study. Setting. Three regions in the Netherlands. Population. 228 cases of perinatal mortality. Methods. Narratives of perinatal mortality cases were assessed by a panel of representatives of all perinatal care provider groups. 123 cases were assessed twice. Consensus was defined as 75% agreement. For the chance corrected agreement Cohen's kappa statistic was used. Main outcome measures. Consensus and the chance corrected agreement on three cause of death classifications. The presence or absence of substandard factors (SSF) with the care provider, the organization of care and the relation of the SSF with perinatal death. Results. Consensus rates and chance corrected agreement for three cause of death classifications ranged from 92 to 96% and kappa 0.87 to kappa 0.93 (very good agreement), with comparable confidence intervals and similar values in the validation subset of 123 cases. On the presence of SSF at the level of the care provider consensus and chance corrected agreement was 68% and kappa 0.53 (moderate), with comparable values in the subset of 123 cases. Consensus for the relation between SSF at the level of the care provider and perinatal death was 81.4% and kappa 0.68 (good). Conclusion. Perinatal audit on a national level with relatively large audit groups with many different care providers is feasible

Comparison of the direct antiglobulin test and the eluate technique for diagnosing haemolytic disease of the newborn

Objective: The direct antiglobulin test (DAT) is an important tool for identification of haemolytic disease of the newborn (HDN) caused by erythrocyte immunization. Although this test has been used for decades, accurate insights into its diagnostic properties and optimal use in the diagnosis of HDN are limited. We aimed to gain more insight into the diagnostic properties of the DAT for HDN by comparing it with erythrocyte eluate screening. Design and methods: DAT and erythrocyte eluate screening was performed in umbilical cord blood of neonates obtained from 317 consecutive deliveries. Clinical jaundice was scored 4â6 days after delivery for the determination of HDN. Results: In 21 neonates a positive DAT and in 61 neonates a positive eluate screening was found, while only 4 cases of HDN were observed. For the overall population the positive predictive value (PPV) and specificity of the DAT for HDN were 10% and 93% respectively and in the population of neonates with abnormal post-partum jaundice population the PPV and specificity were both 100%. The DAT missed two cases of HDN. These missed cases were, however, positive in the erythrocyte eluate screening. Conclusion: The detection of clinically irrelevant ABO immunization limits the specificity of the DAT and eluate for HDN in ABO-incompatible pregnancies. For optimal use, the DAT should be requested only in cases of jaundice and be interpreted in the context of ABO-incompatibility. Finally, a negative DAT does not rule out HDN. When clinical suspicion is high, an eluate should be added following a negative DAT. Keywords: DAT, Haemolytic disease of the newborn, Eluate, Test performance, Sensitivity, Specificity, NPV, PP