Normal obstetric ultrasound reduces the risk of Down syndrome in fetuses of older mothers

The objective of this study is to determine whether a normal fetal morphology ultrasound scan in women older than 35 years reduces the risk of aneuploidy. We reviewed the results of amniocentesis and second trimester sonogram in all women older than 35 years from 1991 to 1995. None had prior screening. We excluded fetuses with structural anomalies. We determined the sensitivity and specificity of minor markers in detecting Down syndrome and also determined the reduction in risk of a normal sonogram. Among the 2060 women older than 35 years giving birth during the study period, 16 (0.78%) delivered an infant with Down syndrome. Of the 16 fetuses, two had no prenatal testing or ultrasound, two had invasive testing but no second trimester sonogram, five had a normal sonogram and seven had one or more sonographic markers of Down syndrome. At least 17% of women older than 35 years did not participate in prenatal testing or ultrasound. Ultrasound detected Down syndrome with a sensitivity of 59% (95% confidence interval: 45–72%), a false‐positive rate of 10.6% (9.4–11.8%) and a positive predictor value of 1 in 9. The likelihood of having normal karyotype if the sonogram was normal was 0.46 (0.31–0.61). In women older than 35 years, a normal second trimester sonogram reduces the risk of Down syndrome by more than 50%. At least 17% of women older than 35 years do not participate in prenatal testing or ultrasound.     

纯氧和空气复苏患儿24个月随访观察

目的 探讨纯氧和空气复苏对新生儿发育的影响,为新生儿复苏用氧选择提供依据.方法 对2005年1月-2007年1月在保定市妇幼保健院进行窒息复苏的30例患儿在24个月时进行随访,依据复苏用氧浓度分为纯氧复苏组(20例)和空气复苏组(10例),内容包括出生时胎龄、出生体重、身长、头围、阿氏评分(1 min,5 min)、心率(1 min,5 min)、随访时体重、身长、头围及运动发育标志(坐、爬、站、走时间).结果 出生时患儿身体数据差异无统计学意义,24个月随访,患儿身高、体重、头围及运动发育标志差异均无统计学意义(P>0.05).结论 空气复苏对新生儿窒息患者是安全有效的.     

Maternal mortality in Pernambuco, Brazil: what has changed in ten years?

This study examines changes in levels and patterns of maternal mortality in Pernambuco, Brazil, in 1994 and 2003. The research was carried out in five sub-regions of Pernambuco using the Reproductive Age Mortality Survey (RAMOS) method and based on death certificates of women of reproductive age registered in the local System of Information on Mortality. In-depth interviews with family members were also conducted for the abortion-related deaths. Of the 1,258 female deaths investigated, 54 maternal deaths were identified, corresponding to a maternal mortality ratio of 77 per 100,000 live births. The estimated level of under-reporting (46%) corresponds to an upward adjustment factor of 1.9. The illegal status of abortion in Brazil remains an important contributory factor for the abortion-related deaths. Approximately 94% of the maternal deaths were judged to be avoidable with improvements in health care. Maternal mortality declined by 30% over the ten-year period but the level of misclassification of maternal deaths remains. Improvements in maternity care for women and reporting of maternal deaths are still urgently needed.     

Status of Women and Infants in Complex Humanitarian Emergencies

Women and children bear the greatest burden in the midst of war and long‐term disasters. Complex humanitarian emergencies are characterized by social disruption, armed conflict, population displacement, collapse of public health infrastructure, and food shortages. Humanitarian assistance for refugees and internally displaced populations requires particular attention to the common issues affecting morbidity and mortality in women and infants. Gender‐based violence and reproductive health concerns are discussed within the context of populations affected by conflict and forced migration. Recommendations for midwives and women's health care providers engaging in care for women and children in complex humanitarian emergencies are discussed.     

5 106例剖宫产手术剖宫产率、指征及母儿预后分析

目的分析剖宫产率升高的原因及指征的变化以及指征与母儿预后的关系。方法对5106例剖宫产手术病例进行回顾性分析。结果平均剖宫产率33.9%,剖宫产率逐年在增加,1995年为25.78%,2003年为43.8%,2004年为40.91%,前后5年间差异有显著性(P<0.001〉。其中以社会因素及胎儿窘迫为指征的剖宫产率增加显著,两组间差异有高度显著性(P<0.01)。剖宫产的上升,围产儿窒息及死亡率并没有明显下降,且在择期剖宫产手术中,子宫切除率及产后出血率较阴道试产后手术组为高。结论剖宫产并不是绝对安全的分娩方式,剖宫产率的升高并没有明显降低围产儿窒息及死亡率。并且,择期剖宫产术的母儿预后较临产后手术母儿预后为差。剖宫产率的上升因素中以社会因素及胎儿窘迫变化最大,因此,剖宫产率的增加已不是一个单纯的医疗问题,而是一个社会问题,应引起广大社会和专家的关注。     

Research on severe maternal morbidities and near-misses in Brazil: what we have learned

The occurrence of complications during pregnancy depends less on the degree of human development than differences in the way complications in pregnancy are detected and managed. It is the quick diagnosis and correct management that really contribute to the enormous differences in maternal mortality ratios between countries and regions. Understanding of the determinants of maternal mortality may be improved by studying cases of severe maternal morbidity. In this paper, various approaches to the concept of severe maternal morbidity and near-misses are discussed, and the relationship between these and maternal deaths. Although no consensus has been reached on a strict definition of near-miss or severe maternal morbidity, we show that the definitions used may be tailored to support diverse objectives, including monitoring progress, epidemiological surveillance and auditing of health care. We conclude that the versatility of the concept, the greater frequency of cases available for study and the possibility of interviewing the survivors of severe complications all support the value of studying severe maternal morbidity to help guide local efforts to reduce maternal mortality. Although this may almost be a reality in developed countries, it continues to represent an important and difficult challenge to overcome in places where its benefits would be most evident.     

Meeting health care needs of women experiencing complications of miscarriage and unsafe abortion: USAID's postabortion care program

Each year, an estimated 210 million women become pregnant. Worldwide, more than one fourth of these pregnancies will end in abortion or an unplanned birth. While many abortions may result from the desire to delay or avoid pregnancy, 15% to 20% of pregnancies will end in miscarriage or stillbirth with some causative agents being malaria, HIV/AIDS, and physical violence. Postabortion care (PAC) is needed to provide treatment for complications caused by incomplete or spontaneous abortion and critical family planning counseling and services to prevent future unplanned pregnancies that may result in repeat abortions. In 2003, the United States Agency for International Development (USAID) initiated a 5-year strategy wherein seven countries were provided financial funding and technical assistance. Since 2003, more than 3000 women have been seen in health centers and health posts for PAC services; more than 14,000 community members have received messages on unsafe abortion; family planning, and complications of unsafe abortion and miscarriage; and more than 600 documents were reviewed for inclusion in a global PAC resource package. This package has been used for developing Cambodia's national PAC policy and for developing patient education materials and provider job aids in Cambodia and Tanzania. These promising methodologies will be replicated in other countries.     

Maternal mortality and maternity care from 1990 to 2005: uneven but important gains

Maternal mortality continues to be the major cause of death among women of reproductive age in many countries. Data from published studies and Demographic and Health Surveys show that gains in reducing maternal mortality between 1990 and 2005 have been modest overall. In 2005, there were about 536,000 maternal deaths, and the maternal mortality ratio was estimated at 400 per 100,000 live births, compared to 430 in 1990. Noteworthy declines took place in east Asia (4% per year) and north Africa (3% per year). Maternal deaths and mortality ratios were highest in sub-Saharan Africa and southeast Asia and low in east Asia and Latin America/Caribbean. In 11 of 53 countries with data, fewer than 25% of women had had at least four antenatal visits. About 63% of births were attended by a skilled attendant: from 47% in Africa to 88% in Latin America/Caribbean. In 16 of 23 countries with data, less than 50% of the recommended levels of emergency obstetric care had been fulfilled. Only 61% of women who delivered in a health facility in 30 developing countries received post-partum care, and far fewer who gave birth at home. Countries with maternal mortality ratios of 750+ per 100,000 live births shared problems of high fertility and unplanned pregnancies, poor health infrastructure with limited resources and low availability of health personnel. The task ahead is enormous.     

Government advice on peanut avoidance during pregnancy – is it followed correctly and what is the impact on sensitization?

BACKGROUND: In 1998, the UK government issued precautionary advice that pregnant or breast-feeding women with a family history of atopy, may wish to avoid eating peanuts during pregnancy and lactation. This study aimed to assess the compliance with this recommendation and investigate its impact upon peanut sensitization. METHODS: A total of 858 children born immediately after the advice were followed for 2 years and assessed for peanut sensitization. A standardized questionnaire was used to ascertain history of atopy and maternal exposure to peanuts during pregnancy. Following parental consent children were skin prick tested to assess sensitization to peanuts. RESULTS: Sixty-five per cent of mothers had avoided peanuts during pregnancy. Forty-two per cent of the mothers had heard about the government advice, and half modified their diet as a consequence. Neither maternal nor family history of atopy had any significant effect on peanut consumption. Parity did play a role, and mothers having their first child were twice as likely to change their diet (P<0.001). Mothers of 77% of the children sensitized to peanuts had avoided peanuts during pregnancy. In this cohort study maternal consumption of peanut during pregnancy was not associated with peanut sensitization in the infant. CONCLUSIONS: The majority of mothers in this cohort avoided peanut consumption during pregnancy. It is likely that either the government advice is misunderstood by mothers, or that those who communicate the advice have not fully explained who it is targeted at.     

The complex enterprise of modelling prenatal exposure to cigarettes: what is ‘enough’?

While there is a burgeoning body of research linking smoking during pregnancy to problem behaviour in offspring, a major criticism of this work has been the crude measurement of exposure in these studies (e.g. retrospective, self-reported only) that could lead to biased estimates. To address this issue, we used a pregnancy cohort with repeated prospective measures of exposure as well as biological assays to generate estimates of exposure patterns using a range of modelling techniques. In this paper we report on the analytical approaches we have developed, including patterns of exposure over time and best-estimate approaches that combine self-report and cotinine measures, and compare their predictive value in relation to different dimensions of fetal growth as a first step towards examining the utility of greater precision of exposure measurement.
Surprisingly, in this sample the more complex assessments of exposure, including biological measures, generally did not perform better than simple indicators of exposure based on repeated self-report measures, with one exception: a combined self-report cotinine 'best estimate' of third trimester exposure was uniquely associated with lower brain : body ratio. Further study is needed using more sophisticated cotinine assays and testing prediction of a range of outcomes to ascertain whether these findings represent true differences or are specific to the sample, methods and outcomes used. Such research will inform the development of guidelines for adequate exposure characterisation in developmental studies.