Treatment of the growth-retarded fetus by augmentation of substrate supply.
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Diet↗
Biomedical subjects
J E Harding
Publications and source records attributed to J E Harding.
The Bristol third stage trial: active versus physiological management of third stage of labour.
OBJECTIVE: To compare the effects on fetal and maternal morbidity of routine active management of third stage of labour and expectant (physiological) management, in particular to determine whether active management reduced incidence of postpartum haemorrhage. DESIGN: Randomised trial of active versus physiological management. Women entered trial on admission to labour ward with allocation revealed just before vaginal delivery. Five months into trial high rate of postpartum haemorrhage in physiological group (16.5% v 3.8%) prompted modification of protocol to exclude more women and allow those allocated to physiological group who needed some active management to be switched to fully active management. Sample size of 3900 was planned, but even after protocol modification a planned interim analysis after first 1500 deliveries showed continuing high postpartum haemorrhage rate in physiological group and study was stopped. SETTING: Maternity hospital. PARTICIPANTS: Of 4709 women delivered from 1 January 1986 to 31 January 1987, 1695 were admitted to trial and allocated randomly to physiological (849) or active (846) management. Reasons for exclusion were: refusal, antepartum haemorrhage, cardiac disease, breech presentation, multiple pregnancy, intrauterine death, and, after May 1986, ritodrine given two hours before delivery, anticoagulant treatment, and any condition needing a particular management of third stage. INTERVENTIONS: All but six women allocated to active management actually received it, having prophylactic oxytocic, cord clamping before placental delivery, and cord traction; whereas just under half those allocated to physiological management achieved it. A fifth of physiological group received prophylactic oxytocic, two fifths underwent cord traction and just over half clamping of the cord before placental delivery. ENDPOINT: Reduction in incidence of postpartum haemorrhage from 7.5% under physiological management to 5.0% under active management. MEASUREMENTS AND MAIN RESULTS: Incidence of postpartum haemorrhage was 5.9% in active management group and 17.9% in physiological group (odds ratio 3.13; 95% confidence interval 2.3 to 4.2), a contrast reflected in other indices of blood loss. In physiological group third stage was longer (median 15 min v 5 min) and more women needed therapeutic oxytocics (29.7% v 6.4%). Apgar scores at one and five minutes and incidence of neonatal respiratory problems were not significantly different between groups. Babies in physiological group weighed mean of 85 g more than those in active group. When women allocated to and receiving active management (840) were compared with those who actually received physiological management (403) active management still produced lower rate of postpartum haemorrhage (odds ratio 2.4;95% CI1.6 to 3.7). CONCLUSIONS: Policy of active management practised in this trial reduces incidence of postpartum haemorrhage, shortens third stage, and results in reduced neonatal packed cell volume.
Breast Feeding↗
Neonatal transport: the Waikato experience.
The experience of the Waikato newborn transport service is reviewed from its inception in September 1980 until December 1986. The service has carried out 599 transports of which 311 were emergency retrievals. Total numbers of transports have increased each year although the demand for emergency retrievals has levelled off. The characteristics of babies requiring emergency retrieval have not changed. One-third of deaths occurred before retrieval could be effected, and 10% of retrieved babies subsequently died. Avoidable deaths seemed uncommon in the latter group. The neonatal transport service is an important part of regionalised perinatal care in the Waikato.
Hospital Planning↗
Studies on the growth of the fetal sheep. Effects of surgical reduction in placental size, or experimental manipulation of uterine blood flow on plasma sulphation promoting activity and on the concentration of insulin-like growth factors I and II.
The effect of long- and short-term manipulations of uterine blood flow on fetal plasma levels of IGF-I and -II have been studied in sheep at days 125-139 of pregnancy and compared with those in near term rats and guinea pig. The primary objective is to show that both long- and short-term reduction of uterine blood flow is associated with increase in the fetal plasma concentration of IGF-II while that of IGF-I falls. In the pregnant sheep long-term depression of utero-placental blood flow was caused by surgical reduction in placental mass (carunclectomy) prior to conception. This reduced fetal weight to 2.42 +/- 0.49 kg (SD) compared with 3.41 +/- 0.46 in controls; the respective values for uterine blood flow being 1694 +/- 558 and 913 +/- 324 ml/min respectively. This was associated with a fall in fetal plasma IGF-I concentration from 22.6 +/- 3.4 ng/ml to 14.9 +/- 1.31 ng/ml and a rise in IGF-II from 1952 +/- 284 ng/ml to 3360 +/- 914 ng/ml respectively. Similar changes in the plasma concentrations of IGF peptides were observed in fetal rats and guinea pigs in response to uterine artery ligation. Short-term reduction (60 min) of the uterine blood flow was caused either by compression of the common uterine artery to depress flow from 1491 +/- 375 to 648 +/- 216 ml/min or through intraarterial infusion of adrenaline at 35 ug/min to lower flow from 1628 +/- 339 to 1195 +/- 128 ml/min. Such falls in uterine blood flow had no significant effect on fetal plasma IGF-I levels but increased IGF-II levels by 30 to 60%.
Animals↗
First year mortality and hospital morbidity after newborn intensive care.
First year mortality and hospital morbidity were studied in 4678 surviving infants liveborn at National Women's Hospital during 1980, of whom 1113 had been admitted to the neonatal intensive care unit. Of children born there, but never admitted to the neonatal unit, 8.3% were hospitalised in their first year for a mean of 6.7 days per admission or 0.8 days per child. Hospitalisation rates were increased in neonatal unit survivors, ranging from 11.6% in normal birthweight to 15.5% in very low birthweight survivors. The hospital admissions were, on average, longer: 11 days per admission or 2.1 days per infant of low birthweight (LBW, under 2500g), and 21 days per admission or 4.8 days per infant of very low birthweight (VLBW, under 1500g). The longer averages reflected long hospital stays by only a few children. Admissions were largely for respiratory infections: no VLBW survivor was admitted for developmental delay, failure to thrive or non-accidental injury. Neonatal unit survivors had no increase in first year mortality compared with other Auckland children, and none died a cot death. Deaths in normal birthweight survivors were due to congenital abnormalities. No VLBW survivor died after discharge from National Women's Hospital. Children surviving neonatal unit care in Auckland in 1980 appeared to have less continuing first year morbidity and mortality than has been reported elsewhere.
Child, Hospitalized↗
Metabolism of glucose by fetus and placenta of sheep. The effects of normal fluctuations in uterine blood flow.
The metabolism by the fetus and placenta of [2-3H, U-14C]glucose infused into fetal sheep has been studied. Uptake of glucose from the fetus by the placenta and transfer to the ewe, as well as placental metabolism of glucose to fructose and lactate have been quantified. About two-thirds of the glucose removed from the fetal circulation was taken up by placenta. Less than 15% of this passed back into the maternal circulation, the remainder was converted, at roughly equivalent rates, into lactate and fructose, most of which was transferred back to the fetus. It seems likely that little of this glucose is oxidised by the placenta. This data indicates that there are substrate cycles between the placenta and fetus, one possible function of which is to limit fetal glucose loss back to the mother; lactate and fructose have limited placental permeability. At uterine blood flow rates in the middle of the normal range net glucose uptake by the placenta from the maternal circulation was about 7-fold higher than that from the fetus. About 20% of this was transported to the fetus, 50% was oxidised and much of the remainder converted to lactate and transferred back to the ewe. Labelling patterns in fructose and lactate make it unlikely that this placental pool of glucose mixes freely with that derived from uptake from the fetus. Net movement of glucose across the placenta is markedly influenced by fluctuations in uterine blood flow over the normal range of 500-3000 ml/min. At low flow rates there is net output of glucose from the fetus to the placenta, and in some instances from the placenta to the ewe, i.e. there is evidence of net utero-placental production of glucose to the ewe separate from output by the fetus. There is a close linear relationship between uterine glucose supply (maternal arterial concentration x uterine blood flow) and net balance across the placenta. As uterine supply of glucose falls there is increased uptake by the placenta of glucose from the fetal circulation and corresponding enhanced recycling of fructose and lactate to the fetus. This production of fructose and lactate by the placenta may function to reduce glucose loss from the fetus to the ewe. Hence at high rates of placental uptake of glucose from the fetus placental production of lactate and particularly fructose may approach saturation and allow significant backflow of glucose from the fetus to the ewe. Under these conditions glucose uptake may in part sustain placental oxygen consumption.
Animals↗
Studies on experimental growth retardation in sheep. The effects of a small placenta in restricting transport to and growth of the fetus.
Fetal and placental growth rate in sheep has been manipulated by removal of endometrial caruncles prior to conception. This produced two groups of fetuses, one in which prenatal growth rate was similar to normal and a second group in which the fetuses were about half of the normal size. The mortality in the latter group was high, particularly after catheterisation, and there was evidence of early intra-uterine death and fetal reabsorption. Prior to 125 days the relationship between fetal and placental size was poor, but after 126 days a close correlation between the two was apparent. The small fetuses had comparably small placentas and in all cases there was a close relationship between fetal and placental weight. The experimental growth retardation was associated with hypoglycaemia, hypoxia and hypoinsulinaemia. Plasma T3, T4 and particularly prolactin were very low in the small fetuses whilst levels of cortisol and alanine were high. In contrast to the controls these fetuses showed little evidence of net glucose, alanine or lactate consumption. Infusion of 50% glucose into the pregnant ewe, sufficient to elevate maternal plasma glucose concentrations 2 to 3 fold, caused a comparable increase in the plasma concentrations of normal fetuses but only a 50% rise in the concentration in small fetuses. In contrast administration of 50% O2 to the ewes sufficient to cause a 2 to 3-fold increase in maternal PO2 caused only a small increase of arterial PO2 of normal fetuses but doubled that to normal levels in small fetuses. The results are discussed in relation to the effect of reduced placental size causing a fall in placental and transport and transport capacity and significance of this to the associated fetal growth retardation.
Age Factors↗
Chronic pain: a disease in itself.
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Chronic Disease↗
Variations in bronchiolitis management between five New Zealand hospitals: can we do better?
OBJECTIVES: To determine the current management of bronchiolitis by five major New Zealand hospitals and to identify areas for improvement. METHODS: Lists of infants under 1 year of age admitted with bronchiolitis during 1998 were obtained from the casemix offices of the five largest New Zealand hospitals with paediatric services. Hospital records from a random sample of these admissions were reviewed. RESULTS: Out of the 409 infants admitted overnight, 8% had been born less than or=32 weeks gestation and 53% were aged younger than 6 months. Overall, 59% received oxygen, 21% had nasogastric fluids, 22% had intravenous fluids, 34% were prescribed antibiotics, 42% received bronchodilators and 60% had a chest radiograph. Respiratory secretions were collected for viral studies from 58% of infants and, in 59%, respiratory syncytial virus was detected. Significant variations in management were detected between hospitals. The overall proportion of infants requiring oxygen, intravenous or nasogastric fluids (65%) was significantly higher than that found in a 1986-1988 Christchurch study where only 25% received one or more of these interventions (P < 0.001). CONCLUSIONS: Opportunities exist to rationalize bronchiolitis management in New Zealand with potential cost savings, particularly by reducing the number of chest radiographs and prescribing of unnecessary antibiotics and bronchodilators.
Anti-Bacterial Agents↗