Practical application of data obtained from a Perinatal Problem Identification Programme.
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Biomedical subjects
G R Howarth
Publications and source records attributed to G R Howarth.
Audit incorporating avoidability and appropriate intervention can significantly decrease perinatal mortality.
OBJECTIVE: To evaluate the role of the ICA (Identification, Cause, Avoidable factor) Solution method of perinatal audit in reducing perinatal mortality. DESIGN: Retrospective audit of 1,060 perinatal deaths between 1 January 1991 and 31 December 1992. SETTING: Livingstone Hospital Maternity Service. SUBJECTS: One thousand and sixty perinatal deaths, where the gestational age exceeded 28 weeks or, when gestational age was unknown, the birth weight was equal to or exceeded 1,000 g. MAIN OUTCOME MEASURES: All perinatal deaths were identified and classified by primary obstetric cause for perinatal loss. In the second year of the study avoidable factors were sought and, if found, graded and categorised. RESULTS: The major primary obstetric causes of perinatal loss identified and amenable to intervention were intrapartum trauma, intrapartum asphyxia and infection. In the second year of study potentially avoidable factors were sought and identified in almost 50% of perinatal deaths. Appropriate intervention lowered the perinatal mortality rate by 23% (P < 0.05; odds ratio 0.76; 95% confidence interval 0.67-0.86). CONCLUSION: The ICA Solution method of perinatal audit identified problems in overall obstetric care, facilitating a significant fall in perinatal mortality.
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Umbilical artery Doppler velocimetry in the prediction of intrapartum fetal compromise.
The value of early intrapartum umbilical artery Doppler velocimetry in the prediction of fetal compromise was studied. One hundred patients were recruited into the study and fetal compromise was diagnosed by abnormal first- or second-stage fetal heart rate traces, a 5-minute Apgar score less than 7, or the development of hypoxic ischaemic encephalopathy. Fetal compromise developed in 30 patients. An umbilical artery resistance index (RI) of 0.66 or less did not predict fetal compromise (sensitivity 13%, specificity 89%, positive predictive value 25%, negative predictive value 70%). Since the mean umbilical artery RI was identical in the compromised and the non-compromised groups, we conclude that early intrapartum Doppler velocimetry is of very little clinical value in predicting fetal compromise at term.
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Infraumbilical-ring capillary abdominocentesis in late presentation ectopic pregnancy: a prospective study.
Infraumbilical-ring capillary abdominocentesis was compared with culdocentesis in 75 cases of suspected ruptured ectopic pregnancy, with patients serving as their own controls. There were 43 proven ectopic cases and the diagnosis was known in the remaining 32. The accuracy of results was equivalent: P greater than 0.15 for false positives and P greater than 0.63 for false negatives. For combined testing the positive predictive value reached 97%. The new method was easier to perform and should be preferred.
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Total perinatal-related wastage in twin pregnancies.
The primary obstetric cause of total perinatal-related wastage (TPRW) in twin pregnancy was studied in a clearly defined population over a 3-year period. There were 77 deaths from 204 pairs of twins; the perinatal mortality rate (PMR) was 51/1,000 and TPRW was 189/1,000. Of the 77 deaths 52% were late abortions, 14% stillbirths, 10% early neonatal deaths, 18% late neonatal deaths and 5% perinatal-related infant deaths. The major obstetric factors leading to TPRW were spontaneous preterm labour (32%), antepartum haemorrhage (30%), infection (16%), unexplained intra-uterine death (10%) and hypertension (8%). The major factors responsible for perinatal-related loss in twin pregnancies are similar to the major factors in singleton pregnancies, but occur earlier in pregnancy. Rather than considering the primary causes of loss in twin pregnancies as a separate entity, we should direct our attention to solving the same obstetric factors responsible for initiating loss in both twin and singleton pregnancies.
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