Obstetric interventions for babies born before 28 weeks of gestation in Europe: results of the MOSAIC study.

OBJECTIVE: To describe obstetric intervention for extremely preterm births in ten European regions and assess its impact on mortality and short term morbidity. DESIGN: Prospective observational cohort study. SETTING: Ten regions from nine countries participating in the 'Models of Organising Access to Intensive Care for Very Preterm Babies in Europe' (MOSAIC) project. POPULATION: All births from 22 to 29 weeks of gestation (n = 4146) in 2003, excluding terminations of pregnancy. METHODS: Comparison of three obstetric interventions (antenatal corticosteroids, antenatal transfer and caesarean section for fetal indication) rates at 22-23, 24-25 and 26-27 weeks to that at 28-29 weeks and the association of the level of intervention with pregnancy outcome. MAIN OUTCOME MEASURES: Use of antenatal corticosteroids, antenatal transfer and caesarean section by two-week gestational age groups as well as a composite score of these three interventions. Outcomes included stillbirth, in-hospital mortality and intraventricular haemorrhage (IVH) grades III and IV and/or periventricular leucomalacia (PVL) and bronchopulmonary dysplasia (BPD). RESULTS: There were large differences between regions in interventions for births at 22-23 and 24-25 weeks. Differences were most pronounced at 24-25 weeks; in some regions these babies received the same care as babies of 28-29 weeks, whereas elsewhere levels of intervention were distinctly lower. Before 26 weeks and especially at 24-25 weeks, there was an association between the composite intervention score and mortality. No association was observed at 26-27 weeks. For survivors at 24-25 weeks, the intervention score was associated with higher rates of BPD, but not with IVH or PVL. CONCLUSIONS: There are large differences between European regions in obstetric practices at the lower limit of viability and these are related to outcome, especially at 24-25 weeks.

Organisation of obstetric services for very preterm births in Europe: results from the MOSAIC project.

OBJECTIVE: To study the impact of the organisation of obstetric services on the regionalisation of care for very preterm births. DESIGN: Cohort study. SETTING: Ten European regions covering 490 000 live births. POPULATION: All children born in 2003 between 24 and 31 weeks of gestation. METHOD: The rate of specialised maternity units per 10 000 total births, the proportion of total births in specialised units and the proportion of very preterm births by referral status in specialised units were compared. MAIN OUTCOME MEASURE: Birth in a specialised maternity unit (level III unit or unit with a large neonatal unit (at least 50 annual very preterm admissions). RESULTS: The organisation of obstetric care varied in these regions with respect to the supply of level III units (from 2.3 per 10 000 births in the Portuguese region to 0.2 in the Polish region), their characteristics (annual number of deliveries, 24 hour presence of a trained obstetrician) and the proportion of all births (term and preterm) that occur in these units. The proportion of very preterm births in level III units ranged from 93 to 63% in the regions. Different approaches were used to obtain a high level of regionalisation: high proportions of total deliveries in specialised units, high proportions of in utero transfers or high proportions of high-risk women who were referred to a specialised unit during pregnancy. CONCLUSION: Consensus does not exist on the optimal characteristics of specialised units but regionalisation may be achieved in different models of organisation of obstetric services.

Termination of pregnancy among very preterm births and its impact on very preterm mortality: results from ten European population-based cohorts in the MOSAIC study.

OBJECTIVE: To study the impact of terminations of pregnancy (TOP) on very preterm mortality in Europe. DESIGN: European prospective population-based cohort study. SETTING: Ten regions from nine European countries participating in the MOSAIC (Models of OrganiSing Access to Intensive Care for very preterm babies) study. These regions had different policies on screening for congenital anomalies (CAs) and on pregnancy termination. POPULATION OR SAMPLE: Births 22-31 weeks gestational age. METHODS: The analysis compares the proportion of TOP among very preterm births and assesses differences in mortality between the regions. MAIN OUTCOME MEASURES: Pregnancy outcomes (termination, antepartum death, intrapartum death and live birth) and reasons for termination, presence of CAs and causes of death for stillbirths and live births in 2003. RESULTS: Pregnancy terminations constituted between 1 and 21.5% of all very preterm births and between 4 and 53% of stillbirths. Most terminations were for CAs, although some were for obstetric indications (severe pre-eclampsia, growth restriction, premature rupture of membranes). TOP contributed substantially to overall fetal mortality rates in the two regions with late second-trimester screening. There was no clear association between policies governing screening and pregnancy termination and the proportion of CAs among stillbirths and live births, except in Poland, where neonatal deaths associated with CAs were more frequent, reflecting restrictive pregnancy termination policies. CONCLUSION: Proportions of TOP among very preterm births varied widely between European regions. Information on terminations should be reported when very preterm live births and stillbirths are compared internationally since national policies related to screening for CAs and the legality and timing of medical terminations differ.

[Low blood pressure in pregnancy]. / Der niedrige Blutdruck in der Schwangerschaft--Ursachen, Folgen und Therapie.

There has been a controversial discussion for decades about the significance of low blood pressure during pregnancy. This review should answer the question, whether low blood pressure itself or the decrease in blood pressure on standing have a negative effect on pregnant women. In addition, we will focus on physiologic and pathophysiologic pregnancy related mechanisms of changes in blood pressure. Subjective symptoms occur more frequently with low blood pressure, however, they disappear at the end of pregnancy. Physiologically, blood pressure decreases towards midpregnancy and rises to preconceptional values at term. Birthweight was directly related to the magnitude and direction of the pressor response on standing in late pregnancy but not to the low blood pressure at rest itself. There is no causal association between low blood pressure and poor perinatal outcomes. It is only an accompanied symptom for other risks in pregnancy. There is a direct relationship between the change in mean arterial blood pressure in standing position and birthweight during late pregnancy. Patients whose pressure falls on standing have the lightest babies.

On the weight-bearing function of the medial coronoid process in dogs.

The shape of and proportions between the surface areas of the medial coronoid process (MCP) and the fovea of the radial head were determined in 88 juvenile dogs and 146 adult dogs grouped as giant, large, mid-sized, chondrodystrophic, or small dogs. Thereby, the longitudinal (length) and transverse (width) extension of the MCP and fovea of the radial head have been measured. Original values were used to describe changes of the parameters attributed to growth. Normalized values (i.e. values expected in case of a width of the fovea of the radial head of 20 mm) were used to determine potential differences between constitutional types. All original values increased during growth (P < 0.05) except for the width and length of the MCP in chondrodystrophic and small breeds. Normalized values revealed a proportional decrease in width and length of the MCP during growth (P < 0.05) compared with the radial head. In adults, the normalized MCP was widest in giant dogs followed by large, mid-sized, small, and chondrodystrophic breeds. The MCP was also longest in giant dogs but shortest in large and chondrodystrophic dogs with those of large dogs being significantly (P < 0.05) shorter than those in giant, mid-sized and small dogs. Present results suggest that a deficiency in length-growth of the MCP--which has been present especially in large dogs--results in smaller humeral contact areas and decreased weight-bearing capacity of the MCP. Because loading forces acting on the MCP increase with body weight, the condition noted in large dogs might increase the risk of fragmentation of the MCP in these.

Postnatal modelling of the humeroantebrachial contact areas of radius and ulna in dogs.

Necropsy dogs (n = 234) ranging in age between 2 days and 17 years were examined to characterize the cross-sectional shape of the humeroantebrachial contact area of the radius and ulna on radioulnar scans of giant, large, mid-sized, small, and chondrodystrophic breeds. During growth, the contact areas became more circular in shape in all breeds, those in small dogs remained most elliptic. Smallest normalized heights (distance between the tip of the anconeal process and the most proximal aspect of the cranial margin of the radial head = RUH, distance between the tip of the anconeal process and the cranial tip of the medial coronoid process = UH) and depths (distance determined in a right angle to RUH = RUD, distance determined in a right angle to UH = UD) were noted in large and giant breeds with no significant difference between these. In juveniles, a decrease in UD was correlated with a decrease in UH in all breeds as was a decrease in RUD correlated with a decrease in RUH, whereas in non-arthrotic adults this condition could only be proven for mid-sized dogs and small breeds but not for giant, large and chondrodystrophic dogs. The average radioulnar and ulnar heights and depths (as seen in non-arthrotic adults) were calculated to be obtained in mid-sized dogs at least 3-4 weeks earlier than in large dogs. Lipping of the cranial margin of the radial head was significantly (P < 0.001) associated with lesion(s) of the articular surface (i.e. erosion of the articular cartilage and subchondral bone and/or fragmentation of the medial coronoid process) and caused additional change in shape of this contact area, which was then even more circular. However, the variables evaluated (RUH, RUD, UH, UD) allowed only poor discrimination between constitution types and between non-arthrotic and arthrotic joints.

The subchondral split line patterns of the medial coronoid process in canine ulnae.

The subchondral split line patterns of the canine medial coronoid process (MCP) were compared with fragmentation line patterns of the MCP in case of elbow dysplasia. Split line patterns were determined in paired ulnae from the killed 26 large-breed dogs ranging in age between 0.8 and 15 years and in two ulnae affected by fragmentation of the MCP. The macerated ulnae were degreased with methylene chloride and decalcified in 5% nitric acid. The subchondral bony layer was pierced at right angles in regular intervals using a round needle that was dipped in black liquid acrylic colour. Three main types of split line patterns could be differentiated (i.e. a sagittal type, a transverse type and an intermediate type). In the sagittal type, split lines were aligned in parallel to the lateral border and at right angles to the rim of the tip and medial border of the MCP. In the transverse type, split lines were orientated in a transverse line to both collateral borders. The intermediate type was characterized as a transition type between sagittal and transverse type as the split lines were aligned obliquely to the longitudinal axis of the MCP. These three types corresponded well with the fissure and fragmentation line patterns of the MCP. The present findings strongly suggest an association between split line pattern and type of fragmentation of the MCP.