Maternal intensive care and near-miss mortality in obstetrics

Objective To determine the level of near-miss maternal mortality and morbidity due to severe obstetrical complications or maternal disease in a tertiary maternity hospital.
Design Retrospective review.
Setting A free-standing maternity hospital delivering 5500 infants per year.
Methods The information coded in the perinatal database concerning women who had required transfer for critical care to a general hospital was reviewed for the 14 year period 1980 to 1993. The complications necessitating transfer and the specialised consultants and services required were noted.
Results Over 14 years there were 76,119 women delivered with two maternal deaths (2.6/100,000). Fifty-five women required transfer for critical care (0.7/1000). The main reasons for transfer were hypertensive disease (25%), haemorrhage (22%) and sepsis (15%). Transfer to an intensive care unit was required by 80%, and the remainder were transferred to specialised medical or surgical units. Twenty different specialist groups were consulted. The 55 patients spent 280 days in critical care and 464 days hospital after-care (mean 13 days, range 3–92).
Conclusion A review of near-miss maternal mortality helps delineate the continuing threats to maternal health and the type of support services most commonly required.     

The impact of diffuseness of coronary artery disease on the outcomes of patients undergoing primary and reoperative coronary artery bypass grafting.

OBJECTIVE: Diffuse coronary artery disease jeopardizes myocardium, increasing surgical mortality in primary coronary artery bypass grafting (CABG). We sought to determine the impact of diffuseness on pre- and post-discharge outcomes for both primary and reoperative CABG (REOP). METHODS: Using a validated system for measuring diffuseness of coronary disease, preoperative angiograms were scored for primary CABG (n=792) and REOP cases (n=268) performed 1997-2004. A diffuseness score (DS)>18 was defined as elevated. In-hospital mortality, intermediate-term survival, and in-hospital composite outcome (COMP) (one or more of: mortality, stroke, MI, deep sternal infection, sepsis, IABP insertion, or return to OR) were examined. RESULTS: In-hospital mortality and COMP for patients with DS>18 were significantly higher (7.9% vs 2.4%, p<0.0001), (17.8% vs 9.2%, p<0.0001). DS (mean+/-SD) was higher in REOP cases than primary CABG (18.9+/-7.1 vs 14.4+/-6.0, p<0.0001). By multivariate analysis, DS>18 (OR 2.00, 95%CI, 1.20-3.32, p=0.008) and REOP (OR 2.40, 95%CI, 1.53-3.77, p<0.0001) were independently associated with COMP. Using propensity scores 82% of cases with DS>18 (n=289) were matched 1:1 to cases with DS18 (6.9% vs 2.8%, p=0.02), (16.6% vs 10.4%, p=0.03). Comparing cases with DS18 and primary CABG versus REOP, survival at 2 years was 92.1% versus 84.5% (p=0.001) and 92.7% versus 82.7% (p<0.0001), respectively. CONCLUSIONS: Diffuse coronary artery disease is an important predictor of morbidity and mortality in primary and REOP CABG patients, and should be considered in both individual patient assessment and risk adjustment.     

Postoperative infections following autologous and homologous blood transfusions

Perioperative homologous blood transfusion has been linked to immune suppression and increased risk of postoperative infection. Autologous blood transfusion may not be associated with increased risk of infection because it presumably is not immunosuppressive. Fifty recipients of preoperatively donated autologous blood were matched to 50 recipients of homologous blood who underwent the same procedure, and the hospital course was reviewed for evidence of postoperative infection in both groups. Postoperative leukocytosis and febrile episodes were more common in homologous blood recipients (17 and 6 vs. 12 and 4, respectively). Sixteen percent of the 50 homologous blood recipients had positive cultures, as compared to 4 percent of the 50 autologous blood recipients (p less than 0.05). This study suggests that the association of blood transfusion with infection may be partially abrogated by the use of autologous blood.     

A profile of the 7500 people in aged-care institutions in Auckland

A study was carried out in 1988 to describe the residents and patients of aged-care institutions in Auckland against which future measures, including planned changes in licensing and funding, could be made. Information was collected for each patient in every hospital (public and private) and each resident in all old people's homes in the Auckland region between January and June 1988. Of the 7516 people surveyed (99.4% response rate), 70% were residents in old people's homes, 25% were patients in private hospitals and 6% were cared for in the public hospital sector. Of the people surveyed, 71% were women. The average age of women, 82 years, was 6.5 years older than that of men. Three-quarters of all women and 44% of men in care were widowed. Women had a higher rate of admission to institutions than did men with almost one in two women and one in four men in the age group 85 years and over being in long term care. Rates of institutionalisation for Maoris and Pacific Islanders were the same as for Europeans. The majority of elderly people received regular contact and concern from family members. This study has demonstrated that Auckland has a higher proportion of the elderly population (7.6% of the population 65 years and over) in long term care compared with other areas of New Zealand.     

Fetal movement monitoring: clinical application

Although many factors influence fetal movements, maternal perception of gross fetal movement appears to be an accurate reflection of fetal activity. Observation in humans and studies in animals indicate that the compromised fetus reduces its oxygen requirements by reducing activity. This fact has enabled perceived fetal movement to become a useful adjunctive test of fetal asphyxia in high-risk pregnancy. Its application to low-risk pregnancy has many attractions, particularly as approximately 50 per cent of stillbirths occur without obvious cause in normal pregnancies. Although studies suggest that such application would be beneficial, questions about acceptability, the burden of further testing precipitated by reports of diminished movement, and the perinatal implications of unwarranted early intervention need to be clarified before the universal application of fetal movement counting protocols can be recommended.     

Adrenoceptor-mediated responses in human skin studied by iontophoresis

The adrenoceptor-mediated responses in human skin (blanching and erythema) were studied by an iontophoretic technique. It is concluded that the receptors in superficial dermal blood vessels belong to the subclasses alpha 1 and beta 2.     

Economic implications of method of delivery

OBJECTIVE: This study was undertaken to examine the costs of hospital care associated with different methods of delivery. STUDY DESIGN: An 18-year population-based cohort study (1985-2002) using the Nova Scotia Atlee Perinatal Database compared outcomes in nulliparous women at term undergoing spontaneous or induced labor for planned vaginal delivery, or undergoing cesarean delivery without labor. Costs that were assessed included physician fees, nursing hours in the labor and delivery, postpartum and neonatal intensive care units, epidural use, induction of labor agents, and consumables. RESULTS: A total of 27,614 pregnancies satisfied inclusion and exclusion criteria, 5233 of which had labor induced. A comparison of mean costs per mother/infant pair demonstrated that cesarean delivery in labor ($2137) was increased compared with spontaneous vaginal delivery ($1340, P=.01), assisted vaginal delivery ($1594, P=.01), and cesarean delivery without labor ($1532, P=.01). The cost of delivery after induction of labor ($1715) was increased compared with spontaneous onset of labor ($1474, P<.001). CONCLUSION: Cesarean delivery in labor occurs more frequently with labor induction and is associated with increased costs compared with other methods of delivery.