Incidence of Intrapartum Abnormal Fetal Heart Rate Pattern in Siriraj Hospital

Objectives: To determine the incidence of intrapartum abnormal fetal heart rate (FHR), possible associated factors and pregnancy outcomes.Materials and Methods: A total of 900 low-risk pregnant women were enrolled in this retrospective cohort study. Obstetric, labor and delivery data were collected. Incidence of intrapartum abnormal FHR pattern was determined, according to the National Institute of Child Health and Human Development (NICHD) classification. Comparisons were made between those with and without abnormal FHR pattern to evaluate possible associated factors and pregnancy outcomes.Results: Mean maternal age was 29.1 years, 55.7% were nulliparous, and mean gestational age at delivery was 38.1 weeks. Incidence of abnormal FHR pattern was 30.7% (30.3% and 0.4% in NICHD category II and III, respectively). Among these, 46.6% and 39.7% occurred in active and deceleration phase of labor, respectively. Univariate analysis showed that rate of abnormal FHR pattern was more common among nulliparous women (RR 1.22, 95% CI 1.003-1.5, p = 0.045). Cesarean delivery was required in 28.9% of cases with abnormal FHR pattern. Birth asphyxia was significantly more common among those with abnormal FHR pattern (7.2% vs. 3.7%, p = 0.016). Multivariate analysis demonstrated that only nulliparity was significantly associated with abnormal FHR pattern (adjusted OR 1.35, 95%CI 1.01-1.82, p = 0.045).Conclusion: Incidence of intrapartum abnormal FHR pattern was 30.7% and nulliparity was the only independent associated factor. The condition significantly increased the risk of birth asphyxia

High-Fidelity Low-Cost Synthetic Training Model for Fetoscopic Spina Bifida Repair

BACKGROUND: Fetoscopic Spina Bifida repair (fSB-repair) is increasingly being practiced, but limited skill acquisition poses a barrier to widespread adoption. Extensive training in relevant models, including both ex- and in-vivo models may help. To address this, a synthetic training model that is affordable, realistic and allows skill analysis would be useful.OBJECTIVE: To create a high-fidelity model for training the essential neurosurgical steps of fetoscopic spina bifida repair using synthetic materials. Additionally, we aimed to obtain a cheap and easily reproducible model.STUDY DESIGN: We developed a three-layered silicon-based model resembling the anatomical layers of a typical myelomeningocele lesion. It allows for filling the cyst with fluid and conducting a water tightness test post-repair. A compliant silicon ball mimics the uterine cavity, and is fixed to a solid 3D printed base. The fetal back with the lesion (single-use) is placed inside the uterine ball, which is reusable and repairable to allow practicing port insertion and fixation multiple times. Following cannula insertion, the uterus is insufflated, and clinical fetoscopic, robotic or prototype instruments can be used. Three skilled endoscopic surgeons each did six simulated fetoscopic repairs following the surgical steps of an open repair. The primary outcome was surgical success, based on water tightness of the repair, operation time &lt;180 minutes and an Objective-Structured-Assessment-of-Technical-Skills (OSATS)-score of ≥ 18/25. Skill retention was measured using a competence commulative sum (C-CUSUM) analysis on composite binary outcome for surgical success. Secondary outcomes were cost and fabrication time of the model.RESULTS: We made a model for simulating spina bifida repair neurosurgical steps with anatomical details, port insertion, placode release and descent, undermining of skin and muscular layer, and endoscopic suturing. The model is made with reusable 3D-printed molds with easily accessible materials. The one-time startup cost was 211€, and each single-use simulated MMC-lesion costs 9.5€ in materials and 50 min working hours. Two skilled endoscopic surgeons performed six simulated three-port fetoscopic repairs, while a third used a Da-Vinci surgical robot. Operation times decreased over 30% from the first to last trial. Six experiments per surgeon did not show an obvious OSATS-score improvement. C-CUSUM analysis confirmed competency for each surgeon.CONCLUSION: This high-fidelity low-cost spina bifida model allows simulated dissection and closure of a myelomeningocele lesion.</p

Early universal screening of gestational diabetes in a university hospital in Thailand

A total of 1016 pregnant women attending antenatal clinic before 20 weeks of gestation during September 2018 to February 2019 were included in a cohort study with repeated cross-sectional assessments. The study was aimed to determine prevalence and characteristics of gestational diabetes mellitus (GDM) and pregnancy outcomes by early universal screening approach. GDM screening was performed during first visit and repeated during 24–28 weeks of gestation, as necessary, using a 50-g glucose challenge test followed by a 100-g oral glucose tolerance test for GDM diagnosis. Overall prevalence of GDM was 18.6%. A significantly higher prevalence of GDM was observed among high-risk than low-risk women (21.3% vs. 13.1%, p = 0.002). GDM among low-risk women contributed to 23.3% of all GDM cases. The majority of GDM (76.2%) were diagnosed before 20 weeks of gestation, with 74.5% occurring in high-risk women and 81.8% occurring in low-risk women. When initial screening tests were normal, risk of GDM diagnosed during 24–28 weeks was 6.0% (7.5% among high-risk women and 3.1% among low-risk women). Compared to those without GDM, women with GDM significantly had lower gestational weight gain (p < 0.001), higher prevalence of preeclampsia (p = 0.001), large for gestational age (LGA) (p = 0.034) and macrosomia (p = 0.004). These outcomes were more pronounced among high-risk women with GDM. Impact Statement What is already known on this subject? Universal GDM screening is recommended during 24–28 weeks of gestation, either by 1- or 2-step approach. Some also recommend early GDM screening among high-risk women. Prevalence of early-onset GDM varies between studies and benefits of early diagnosis and treatment are still controversial. What do the results of this study add? Early universal GDM screening identified more women with GDM and majority could be diagnosed before 20 weeks of gestation. GDM among low-risk women contributed to 23.3% of all cases. Adverse pregnancy outcomes were more common among high-risk women with GDM. This approach could be useful and can be implemented in other settings, especially those that serve high-risk population or with high GDM prevalence. What are the implications of these findings for clinical practice and/or further research? Early universal GDM screening should be considered in settings with high prevalence of GDM and high-risk women. However, benefits of early detection and treatment of GDM should be determined in more details in the future, especially in terms of cost-effectiveness and improvement in pregnancy outcomes

Outcomes of Expectant Management in HIV-Infected Pregnancy with Preterm Premature Rupture of Membranes at Less Than 34-Week Gestation: A Case Series

Objective: To present outcomes of expectant management (EM) in HIV-infected pregnancy with preterm premature rupture of membranes (PPROM) at less than 34-week gestation. Case presentation: During January 2008-December 2015, there were 513 HIV-infected pregnant women giving birth at Siriraj Hospital, Thailand. Ten of them presented with PPROM at GA <34 weeks and six women received EM. The deliveries took place at GA 28 2/7 - 33 5/7 weeks. The longest interval of ROM was 15 days and the highest on-admission viral load was 633,000 copies/mL. Three of them had antepartum highly active antiretroviral therapy (HAART) for at least four weeks prior to the delivery. Mode of delivery included 3 vaginal deliveries and 3 caesarean sections. All infants’ HIV molecular tests were negative at birth. The longest follow-up interval was 12 months and HIV vertical transmission remained negative. Conclusion: Expectant management in HIV-infected women with PPROM at GA <34 weeks may be sensible because complications of prematurity outweigh the risk of vertical HIV transmission

Nurses as substitutes for doctors in primary care

BACKGROUND: Current and expected problems such as ageing, increased prevalence of chronic conditions and multi-morbidity, increased emphasis on healthy lifestyle and prevention, and substitution for care from hospitals by care provided in the community encourage countries worldwide to develop new models of primary care delivery. Owing to the fact that many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing. Substitution of nurses for doctors is one strategy used to improve access, efficiency, and quality of care. This is the first update of the Cochrane review published in 2005. OBJECTIVES: Our aim was to investigate the impact of nurses working as substitutes for primary care doctors on:* patient outcomes;* processes of care; and* utilisation, including volume and cost. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), part of the Cochrane Library (www.cochranelibrary.com), as well as MEDLINE, Ovid, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EbscoHost (searched 20.01.2015). We searched for grey literature in the Grey Literature Report and OpenGrey (21.02.2017), and we searched the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov trial registries (21.02.2017). We did a cited reference search for relevant studies (searched 27.01 2015) and checked reference lists of all included studies. We reran slightly revised strategies, limited to publication years between 2015 and 2017, for CENTRAL, MEDLINE, and CINAHL, in March 2017, and we have added one trial to 'Studies awaiting classification'. SELECTION CRITERIA: Randomised trials evaluating the outcomes of nurses working as substitutes for doctors. The review is limited to primary healthcare services that provide first contact and ongoing care for patients with all types of health problems, excluding mental health problems. Studies which evaluated nurses supplementing the work of primary care doctors were excluded. DATA COLLECTION AND ANALYSIS: Two review authors independently carried out data extraction and assessment of risk of bias of included studies. When feasible, we combined study results and determined an overall estimate of the effect. We evaluated other outcomes by completing a structured synthesis. MAIN RESULTS: For this review, we identified 18 randomised trials evaluating the impact of nurses working as substitutes for doctors. One study was conducted in a middle-income country, and all other studies in high-income countries. The nursing level was often unclear or varied between and even within studies. The studies looked at nurses involved in first contact care (including urgent care), ongoing care for physical complaints, and follow-up of patients with a particular chronic conditions such as diabetes. In many of the studies, nurses could get additional support or advice from a doctor. Nurse-doctor substitution for preventive services and health education in primary care has been less well studied.Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low- or moderate-certainty evidence):* Nurse-led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor-led care. However, the results vary and it is possible that nurse-led primary care makes little or no difference to the number of deaths (low-certainty evidence).* Blood pressure outcomes are probably slightly improved in nurse-led primary care. Other clinical or health status outcomes are probably similar (moderate-certainty evidence).* Patient satisfaction is probably slightly higher in nurse-led primary care (moderate-certainty evidence). Quality of life may be slightly higher (low-certainty evidence).We are uncertain of the effects of nurse-led care on process of care because the certainty of this evidence was assessed as very low.The effect of nurse-led care on utilisation of care is mixed and depends on the type of outcome. Consultations are probably longer in nurse-led primary care (moderate-certainty evidence), and numbers of attended return visits are slightly higher for nurses than for doctors (high-certainty evidence). We found little or no difference between nurses and doctors in the number of prescriptions and attendance at accident and emergency units (high-certainty evidence). There may be little or no difference in the number of tests and investigations, hospital referrals and hospital admissions between nurses and doctors (low-certainty evidence).We are uncertain of the effects of nurse-led car

Contrôle de la qualité des soins: aspects épidémiologiques. [Quality control of health care: epidemiological aspects].

Quality control in health care should be performed by health professionals. To do so they must define indicators, set up studies aimed at measuring and analyzing quality of care, and implement quality assurance programs in health care systems. The elements of a quality improvement program of this kind are described, with special emphasis on the contribution of epidemiology in this field

Appraiser recommendations for use of guidelines.

<p>Appraiser recommendations for use of guidelines.</p

Scaled domain percentages for all appraisers for each guideline.

<p>Scaled domain percentages for all appraisers for each guideline.</p

Immunogenicity and reactogenicity of heterologous COVID-19 vaccination in pregnant women

This open-labeled non-inferiority trial evaluated immunogenicity and reactogenicity of heterologous and homologous COVID-19 vaccination schedules in pregnant Thai women. 18–45-year-old pregnant women with no history of COVID-19 infection or vaccination and a gestational age of ≥12 weeks were randomized 1:1:1 into three two-dose primary series scheduled 4 weeks apart: BNT162b2-BNT162b2 (Group 1), ChAdOx1-BNT162b2 (Group 2), and CoronaVac-BNT162b2 (Group 3). Serum antibody responses, maternal and cord blood antibody levels at delivery, and adverse events (AEs) following vaccination until delivery were assessed. The 124 enrolled participants had a median age of 31 (interquartile range [IQR] 26.0–35.5) years and gestational age of 23.5 (IQR 18.0–30.0) weeks. No significant difference in anti-receptor binding domain (RBD) IgG were observed across arms at 2 weeks after the second dose. Neutralizing antibody geometric mean titers against the ancestral Wuhan strain were highest in Group 3 (258.22, 95% CI [187.53, 355.56]), followed by Groups 1 (187.47, 95% CI [135.15, 260.03]) and 2 (166.63, 95% CI [124.60, 222.84]). Cord blood anti-RBD IgG was correlated with, and equal to or higher than, maternal levels at delivery (r = 0.719, P < .001) and inversely correlated with elapsed time after the second vaccination (r = −0.366, P < .001). No significant difference in cord blood antibody levels between groups were observed. Local and systemic AEs were mild-to-moderate and more frequent in Group 2. Heterologous schedules of CoronaVac-BNT162b2 or ChAdOx1-BNT162b2 induced immunogenicity on-par with BNT162b2-BNT162b2 and may be considered as alternative schedules for primary series in pregnant women in mRNA-limited vaccine settings

Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis

Summary: Background: Preterm birth is the leading cause of death in children younger than 5 years worldwide. Although preterm survival rates have increased in high-income countries, preterm newborns still die because of a lack of adequate newborn care in many low-income and middle-income countries. We estimated global, regional, and national rates of preterm birth in 2014, with trends over time for some selected countries. Methods: We systematically searched for data on preterm birth for 194 WHO Member States from 1990 to 2014 in databases of national civil registration and vital statistics (CRVS). We also searched for population-representative surveys and research studies for countries with no or limited CRVS data. For 38 countries with high-quality data for preterm births in 2014, data are reported directly. For countries with at least three data points between 1990 and 2014, we used a linear mixed regression model to estimate preterm birth rates. We also calculated regional and global estimates of preterm birth for 2014. Findings: We identified 1241 data points across 107 countries. The estimated global preterm birth rate for 2014 was 10·6% (uncertainty interval 9·0–12·0), equating to an estimated 14·84 million (12·65 million–16·73 million) live preterm births in 2014. 12· 0 million (81·1%) of these preterm births occurred in Asia and sub-Saharan Africa. Regional preterm birth rates for 2014 ranged from 13·4% (6·3–30·9) in North Africa to 8·7% (6·3–13·3) in Europe. India, China, Nigeria, Bangladesh, and Indonesia accounted for 57·9 million (41×4%) of 139·9 million livebirths and 6·6 million (44×6%) of preterm births globally in 2014. Of the 38 countries with high-quality data, preterm birth rates have increased since 2000 in 26 countries and decreased in 12 countries. Globally, we estimated that the preterm birth rate was 9×8% (8×3–10×9) in 2000, and 10×6% (9×0–12×0) in 2014. Interpretation: Preterm birth remains a crucial issue in child mortality and improving quality of maternal and newborn care. To better understand the epidemiology of preterm birth, the quality and volume of data needs to be improved, including standardisation of definitions, measurement, and reporting. Funding: WHO and the March of Dimes