Does perinatal exposure to exogenous oxytocin influence child behavioural problems and autistic-like behaviours to 20 years of age?

BACKGROUND: The neuropeptide and hormone oxytocin is known to have a significant impact on social cognition and behaviour in humans. There is growing concern regarding the influence of exogenous oxytocin (OT) administration in early life on later social and emotional development, including autism spectrum disorder (ASD). No study has examined offspring development in relation to the dose of exogenous oxytocin administered during labour. METHODS: Between 1989 and 1992, 2,900 mothers were recruited prior to the 18th week of pregnancy, delivering 2,868 live offspring. The Child Behaviour Checklist was used to measure offspring behavioural difficulties at ages 5, 8, 10, 14 and 17 years. Autism spectrum disorder was formally diagnosed by consensus of a team of specialists. At 20 years, offspring completed a measure of autistic-like traits, the Autism Spectrum Quotient (AQ). Oxytocin exposure prior to birth was analysed using categorical and continuous approaches (maternal oxytocin dose) with univariate and multivariate statistical techniques. RESULTS: Categorical analyses of oxytocin exposure prior to birth demonstrated no group differences in any measures of child behaviour. A small in magnitude dose-response association was observed for clinically significant total behaviour symptoms (adjusted odds ratio 1.03; 95% CI: 1.01-1.06, p < .01). Exogenous oxytocin administration prior to birth was not associated with ASD (OR: 0.64; 95% CI: 0.15-2.12, p = .46) or high levels of autistic-like traits (p = .93), as assessed by the AQ. CONCLUSIONS: This study is the first to investigate longitudinal mental health outcomes associated with the use of oxytocin-based medications during labour. The results do not provide evidence to support the theory that exogenous OT has a clinically significant negative impact on the long-term mental health of children.

Cost effectiveness of universal umbilical cord blood gas and lactate analysis in a tertiary level maternity unit.

OBJECTIVE: There is an increasing body of literature supporting universal umbilical cord blood gas analysis (UCBGA) into all maternity units. A significant impediment to UCBGA's introduction is the perceived expense of the introduction and associated ongoing costs. Consequently, this study set out to conduct the first cost-effectiveness analysis of introducing universal UCBGA. METHODS: Analysis was based on 42,100 consecutive deliveries ≥23 weeks of gestation at a single tertiary obstetric unit. Within 4 years of UCBGA's introduction there was a 45% reduction in term special care nursery (SCN) admissions >2499 g. Incurred costs included initial and ongoing costs associated with universal UCBGA. Averted costs were based on local diagnosis-related grouping costs for reduction in term SCN admissions. Incremental cost-effectiveness ratio (ICER) and sensitivity analysis results were reported. RESULTS: Under the base-case scenario, the adoption of universal UCBGA was less costly and more effective than selective UCBGA over 4 years and resulted in saving of AU$641,532 while adverting 376 SCN admissions. Sensitivity analysis showed that UCBGA was cost-effective in 51.8%, 83.3%, 99.6% and 100% of simulations in years 1, 2, 3 and 4. These conclusions were not sensitive to wide, clinically possible variations in parameter values for neonatal intensive care unit and SCN admissions, magnitude of averted SCN admissions, cumulative delivery numbers, and SCN admission costs. CONCLUSIONS: Universal UCBGA is associated with significant initial and ongoing costs; however, potential averted costs (due to reduced SCN admissions) exceed incurred costs in most scenarios.

The impact of introducing universal umbilical cord blood gas analysis and lactate measurement at delivery.

BACKGROUND: There is growing support for umbilical cord blood gas analysis (UCBGA) to be conducted at delivery. A recent study in a tertiary level obstetric unit found that universal UCBGA was associated with improved perinatal outcomes, but there is less evidence of benefit in lower-risk environments. In such settings, lactate analysis may be a suitable alternative. AIMS: This study evaluated the introduction of universal UCBGA into a secondary obstetric unit and universal umbilical cord lactate analysis program into primary and secondary units. METHODS: After education, universal UCBGA or lactate analysis was introduced into one primary and two secondary level obstetric units. Univariate and adjusted analysis assessed changes in UCBGA values and Apgar scores over the study period. RESULTS: There were no significant changes in mean blood gas and lactate values at any centre following introduction of universal UCBGA or lactate analysis. However, there was at the primary level obstetric unit a significant reduction in the proportion of neonates with moderate to severe elevations in umbilical artery lactate values. There was a non-significant reduction in arterial pH values less than 7.10 at the secondary metropolitan centre. CONCLUSION: The data presented in this study suggest that the benefits of introducing UCBGA into a tertiary obstetric centre may be reproduced in a primary obstetric centre within 12 months of implementation. Larger studies are required in secondary units to assess infrequent adverse obstetric and neonatal outcomes.

Attitudes and barriers to the introduction of umbilical cord blood gas and lactate analysis at birth.

BACKGROUND: Despite a growing body of evidence demonstrating the value of universal umbilical cord blood gas analysis (UCBGA), there remains reluctance in some maternity units to adopt universal testing. AIMS: Identify perceived barriers and benefits of universal UCBGA. METHODS: Medical and midwifery staff involved in intrapartum care at four level two maternity units (one metropolitan and three regional) completed questionnaires evaluating attitudes to UCBGA. Questionnaires included 13 statements with responses ranging from strongly agree to strongly disagree and background demographic data. RESULTS: Most respondents considered UCBGA beneficial to perinatal care (n = 72; 67.3%), with only nine individuals (8.4%) believing UCBGA had no place in perinatal care. The majority of respondents considered benefits of UCBGA to include being an effective and objective marker of neonatal status (n = 64; 59.8%), as well as playing a role in medicolegal issues (n = 74; 69.2%) and audit and teaching (n = 64; 59.8%). Respondents considered that barriers to universal UCBGA introduction included insufficient time following delivery, increased workload and encroachment of technology into birth. CONCLUSIONS: The majority of respondents indicated support for UCBGA. Information derived from this study may be useful in identifying and resolving concerns prior to the introduction of UCBGA. Further, it could be useful in the preparation of education and implementation packages necessary for introduction of UCBGA.

Accurate prediction of hypoxic-ischaemic encephalopathy at delivery: a cohort study.

OBJECTIVE: Hypoxic-ischaemic encephalopathy (HIE) is a major acute neurologic manifestation of perinatal asphyxia associated with significant mortality and morbidity. The study aimed to develop a simple, accurate method of predicting HIE at delivery. METHODS: Between January 2003 and December 2009, all HIE cases were identified from the 38,404 deliveries at a single tertiary centre. Receiver operating curve (ROC) analysis and multivariate logistic regression assessed the ability of clinical and biochemical assessments to predict HIE. RESULTS: Sixty neonates met the HIE criteria: 39 were moderate-severe HIE. Univariate analyses identified clinical neonatal markers (Apgar scores and neonatal resuscitation level) to be better HIE predictors than biochemical markers (umbilical artery pH, base excess and lactate values). Multivariable models using two to four predictors had areas under ROC curves up to 0.98, sensitivities up to 93% and specificities up to 99%. For moderate-severe HIE, the most effective predictor was neonatal resuscitation level and arterial lactate (ROC 0.98, sensitivity 85%, specificity 99%). CONCLUSION: The combination of umbilical arterial lactate and neonatal resuscitation level provides a rapid and accurate method of predicting moderate-severe HIE that can identify neonates at birth that may benefit from tertiary care and neuroprotective therapies.

The effect of time, temperature and storage device on umbilical cord blood gas and lactate measurement: a randomized controlled trial.

OBJECTIVE: Umbilical cord blood gas analysis has a significant and growing role in early neonatal assessment. Factors often delay analysis of cord blood allowing values to change. Consequently, this study evaluates the impact of time, temperature and method of storage on umbilical blood gas and lactate analyses. METHODS: Umbilical cord segments from 80 singleton deliveries were randomized to: cords at room temperature (CR), cords stored on ice (CI), syringes at room temperature (SR) or syringes stored on ice (SI). Analysis occurred every 15 minutes for one-hour. Mixed model analysis of variance allowing for repeated measures was utilized. RESULTS: Cord arterial pH deteriorated in CR, CI, and SI within 15 minutes (p ≤ 0.001), with SR stable until 60 minutes (p = 0.002). Arterial pCO(2) remained stable in SR and CI, increased in SI (p = 0.002; 45 minutes) and decreased in CR (p < 0.001; 45 minutes). Arterial base excess deteriorated in CR and SI (p ≤ 0.009; 15 minutes), SR (p < 0.001; 30 minutes), and CI (p < 0.001; 45 minutes). Arterial lactate levels increased within 15 minutes in all groups (p < 0.001). CONCLUSIONS: Cord blood gas values change rapidly after delivery. Smallest changes were seen in SR group. Data suggest that analyses should be conducted as soon as possible after delivery.

Benefits of introducing universal umbilical cord blood gas and lactate analysis into an obstetric unit.

BACKGROUND: Current evidence suggests that umbilical arterial pH analysis provides the most sensitive reflection of birth asphyxia. However, there's debate whether umbilical cord blood gas analysis (UC-BGA) should be conducted on some or all deliveries. AIM: The aim of this study was to evaluate the impact of introducing universal UC-BGA at delivery on perinatal outcome. METHODS: An observational study of all deliveries > or =20 weeks' gestation at a tertiary obstetric unit between January 2003 and December 2006. Paired UC-BGA was performed on 97% of deliveries (n = 19,646). Univariate and adjusted analysis assessed inter-year UC-BGA differences and the likelihood of metabolic acidosis and nursery admission. RESULTS: There was a progressive improvement in umbilical artery pH, pO(2), pCO(2), base excess and lactate values in univariate and adjusted analyses (P < 0.001). There was a significant reduction in the newborns with an arterial pH <7.10 (OR = 0.71; 95%CI 0.53-0.95) and lactate >6.1 mmol/L (OR = 0.37; 95%CI 0.30-0.46). Utilising population specific 5th and 95th percentiles, there was a reduction in newborns with arterial pH less than 5th percentile (pH 7.12; OR = 0.75; 95%CI 0.59-0.96) and lactate levels greater than 95th percentile (6.7 mmol/L; OR = 0.37; 95%CI 0.29-0.49). There was a reduction in term (OR = 0.65; 95%CI 0.54-0.78), and overall (OR = 0.75; 95%CI 0.64-0.87) nursery admissions. These improved perinatal outcomes were independent of intervention rates. CONCLUSIONS: These data suggest that introduction of universal UC-BGA may result in improved perinatal outcomes, which were observed to be independent of obstetric intervention. We suggest that these improvements might be attributed to provision of biochemical data relating to fetal acid-base status at delivery influencing intrapartum care in subsequent cases.