Sonographically determined anomalies and outcome in 170 chromosomally abnormal fetuses

Structural pathology and outcome were studied in 170 chromosomally abnormal fetuses. Numerical chromosomal abnormalities were established in 158 (93 per cent) cases, of which 110 (71 per cent) represented trisomies, 30 (18 per cent) Turner syndrome, and 18 (11 per cent) triploidy. Structural chromosomal abnormalities were diagnosed in 12 (7 per cent) cases. Gestational age at referral was significantly shorter for pregnancies with Turner syndrome than for the other chromosomal abnormalities. Referral before 20 weeks of gestation was mainly based on fetal structural pathology alone (92 per cent); after 20 weeks, patients were referred because of structural pathology combined with small for gestational age, oligohydramnios, or polyhydramnios. Referral as a result of suspected multiple organ pathology occurred in 73.5 per cent of pregnancies. An abnormal amniotic fluid volume was present in 59/170 (34.5 per cent) chromosomally affected pregnancies, i.e., oligohydramnios in 31 and polyhydramnios in 28 cases. Birth weight was below the tenth percentile in over half of the chromosomally abnormal fetuses, except for Turnersyndrome. Fetal outcome was poor, with a survival rate at 1 month of 30 per cent for trisomies which was mainly determined by trisomy 21 (14/18=77.5 per cent)

Behavior-state-dependent changes in human fetal pulmonary blood flow velocity waveforms

Objective: To establish the influence of fetal behavior stateson venous and arterial pulmonary blood flow velocity waveformsin the normally developing term fetus.Methods: The relation between venous and arterial pulmonaryblood flow velocity waveforms and fetal behaviorstates was investigated in 18 normal term fetuses. Recordingsof the venous pulmonary blood flow velocity waveformswere obtained just proximal to the entrance in the leftatrium, and the arterial pulmonary blood flow velocitywaveforms were taken from the most proximal branch of thepulmonary artery in the same lung using color Dopplerimaging. Time-averaged peak systolic, peak diastolic, andend-diastolic flow velocity; peak systolic to peak diastolicratio; pulsatility index; and fetal heart rate were calculatedfrom both venous and arterial Doppler recordings obtainedduring behavior states 1F (quiet sleep) and 2F (active sleep).Fetal behavior states were determined from combined recordingsof fetal eye and body movements.Results: Recordings of sufficient quality for analysis wereobtained from ten fetuses. Venous pulmonary blood flowvelocity waveforms demonstrated a statistically significantincrease in time-averaged peak diastolic and end-diastolicvelocity during fetal behavior state 2F. No behavior-staterelatedchanges were observed for the arterial pulmonaryblood flow velocity waveform.Conclusion: The data suggest an increased pressure gradientbetween the pulmonary venous system and the leftatrium during behavior state 2F. Flow velocity waveformsfrom the proximal arterial pulmonary branch are independentof behavioral state

Technology assessment and knowledge brokering: the case of assisted reproduction in The Netherlands

OBJECTIVES: Even when policy makers show interest and evidence-informed and convincing HTA studies are available, use of assessment products is not guaranteed. In this article, we report our experience with knowledge brokering to foster evidence-informed policy making on cost-effective treatment and reimbursement of assisted reproduction in The Netherlands. METHODS: From earlier work in the field of knowledge brokering, we foresaw the need for a deliberative strategy to manage the inherent tension between scientific rigor demanded by researchers and responsiveness to real-time needs demanded by policy makers. Therefore, we structured the process in three distinct steps: (i) agreement about the main messages from the research, (ii) analysis of the policy context and of the meaning of the main messages for the actors involved, and (iii) an invitational meeting to make recommendations for action. RESULTS: One of the recommendations that would require changes in ministerial policy was followed up instantly, whereas the other recommendation is still under debate. The Dutch Society of Obstetrics and Gynecology activated the revision of two guidelines. The patient organization uses the new scientific insights in informing members and the public. Closing the loop, The Netherlands Organisation for Health Research and Development (ZonMw) funded research to close knowledge gaps that became apparent in the process. CONCLUSIONS: Knowledge brokering is a promising approach to bring HTA into practice. We conclude that the methodologies to feed research results into the policy process are still in an incipient stage and need further developmen

Survival after non-aggressive obstetric management in cases of severe fetal anomalies: a retrospective study

Obstetricians may choose to refrain from interventions aimed at sustaining fetal life (i.e., non-aggressive obstetric management) when the fetus has an extremely poor prognosis. However, if the infant is then born alive, crucial neonatal management decisions then have to be made. We sought empirical data concerning such perinatal end-of-life decisions. Firstly, to describe survival during delivery and after birth following non-aggressive obstetric management, and secondly, to describe neonatal management in infants born alive after non-aggressive obstetric management. Retrospective descriptive study. Tertiary centre. Eighty-one infants born to women who opted for a non-aggressive obstetric management policy because of sonographically diagnosed severe fetal anomaly. Data were collected from obstetric and neonatal records, as well as ultrasound reports. Survival, neonatal management and health status after birth. Relevant data were available for 78/80 (98%) infants. Six (8%) infants died in utero, 16 (21%) died during delivery (11 from cephalocentesis) and 56 (72%) were born alive. Life-sustaining neonatal treatment was initiated in 29 (52%) of the live-born infants. Twenty-three of these 29 (79%) infants died within six months of birth. Of the 27 live-born infants who did not receive neonatal life-sustaining treatment, 25 (93%) died. Eight infants survived; all with severe health problems. Life-sustaining neonatal support after non-aggressive obstetric management in the presence of severe fetal malformation has little impact on surviva