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BMJ Open Quality Aug 2022Perinatal Excellence to Reduce Injury in Premature Birth (PERIPrem) is an 11-element perinatal care bundle designed to improve outcomes for preterm babies, in line with...
Perinatal Excellence to Reduce Injury in Premature Birth (PERIPrem) is an 11-element perinatal care bundle designed to improve outcomes for preterm babies, in line with the National Health Service (NHS) Long Term plan. Designed in collaboration with 12 NHS Trusts (secondary care hospitals), South West and West of England Academic Health Science Networks, South West Neonatal Operational Delivery Network, parent partners and clinical experts, implementation was via bespoke quality improvement (QI) methodology. Before project initiation, there was regional variation in uptake of elements, evidenced by baseline audit. Optimisation of the preterm infant is complex; eligibility for treatments is dependent on gestation and local policies. Preterm infants experience variability in care dependent on the place of birth, and there remains an implementation gap for several effective, evidence-based treatments.The PERIPrem ambition is to reduce severe brain injury and death caused by prematurity by at least 50% through the delivery of a perinatal care bundle. The PERIPrem approach resulted in improved element implementation by 26% (from 3% to 29%) between 2019 and 2021, with dyads significantly more likely to receive the full bundle in 2021 compared with 2019 (probability=0.96 (95% CI 0.87 to 0.99), p<0.001). When examining the impact on psychological safety and team-working of PERIPrem, linear mixed models indicated an improvement in team function (p=0.021), situation monitoring (p=0.029) and communication within teams (p=0.002). Central to success was the development of a committed multiorganisational collaborative that continues to drive perinatal improvement using a common language and streamlining processes. In addition to saving the lives of the most vulnerable babies, PERIPrem aims to improve the chances of disability-free lives and is successfully nurturing high-functioning perinatal teams with enhanced QI skills.
Topics: England; Female; Humans; Infant; Infant, Newborn; Infant, Premature; Pregnancy; Premature Birth; Quality Improvement; State Medicine
PubMed: 35944934
DOI: 10.1136/bmjoq-2022-001904 -
American Journal of Obstetrics &... Jul 2023Cervical cerclage is a recognized intervention in the management of women at risk of preterm birth and midtrimester loss. The mechanism of action of cerclage is unclear,... (Observational Study)
Observational Study
BACKGROUND
Cervical cerclage is a recognized intervention in the management of women at risk of preterm birth and midtrimester loss. The mechanism of action of cerclage is unclear, and the technique has been poorly researched.
OBJECTIVE
This study aimed to evaluate cerclage technique among experienced obstetricians, using a previously developed and evaluated cerclage simulator.
STUDY DESIGN
This prospective experimental simulation and observational study used identical simulators for 28 consultant obstetricians who were asked to perform their normal cerclage. Suture type, height, knot site, and free thread length were recorded. Using computed tomography, depth of bite and tension (by reduction in area of cervix) were calculated.
RESULTS
A total of 52 cervical cerclages were completed (Mersilene tape, n=20; monofilament suture, n=32). Mean suture height was 33 mm (standard deviation, 7.7 mm), greater with monofilament suture than with Mersilene tape, and associated with smaller needle size. Mean depth of bite and mean reduction of starting area did not differ by suture type. Seven procedures showed ≥1 suture bite that had entered the cervical canal once or more.
CONCLUSION
This study assessed cerclage technique of experienced obstetricians using simulators and computed tomography imaging, and demonstrated wide variation in technique; this may affect the efficacy of the procedure. Further work should establish optimal technique and consensus for training and clinical practice.
Topics: Female; Humans; Infant, Newborn; Pregnancy; Cerclage, Cervical; Cervix Uteri; Premature Birth; Prospective Studies; Sutures
PubMed: 37080297
DOI: 10.1016/j.ajogmf.2023.100961 -
EBioMedicine Jul 2023Climate change, in particular the exposure to heat, impacts on human health and can trigger diseases. Pregnant people are considered a vulnerable group given the...
BACKGROUND
Climate change, in particular the exposure to heat, impacts on human health and can trigger diseases. Pregnant people are considered a vulnerable group given the physiological changes during pregnancy and the potentially long-lasting consequences for the offspring. Evidence published to date on higher risk of pregnancy complications upon heat stress exposure are from geographical areas with high ambient temperatures. Studies from geographic regions with temperate climates are sparse; however, these areas are critical since individuals may be less equipped to adapt to heat stress. This study addresses a significant gap in knowledge due to the temperature increase documented globally.
METHODS
Birth data of singleton pregnancies (n = 42,905) from a tertiary care centre in Hamburg, Germany, between 1999 and 2021 were retrospectively obtained and matched with climate data from the warmer season (March to September) provided by the adjacent federal meteorological station of the German National Meteorological Service to calculate the relative risk of heat-associated preterm birth. Heat events were defined by ascending temperature percentiles in combination with humidity over exposure periods of up to 5 days. Further, ultrasound data documented in a longitudinal prospective pregnancy cohort study (n = 612) since 2012 were used to identify pathophysiological causes of heat-induced preterm birth.
FINDINGS
Both extreme heat and prolonged periods of heat exposure increased the relative risk of preterm birth (RR: 1.59; 95% CI: 1.01-2.43; p = 0.045; RR: 1.20; 95% CI: 1.02-1.40; p = 0.025). We identified a critical period of heat exposure during gestational ages 34-37 weeks that resulted in increased risk of late preterm birth (RR: 1.67; 95% CI: 1.14-1.43; p = 0.009). Pregnancies with a female fetus were more prone to heat stress-associated preterm birth. We found heat exposure was associated with altered vascular resistance within the uterine artery.
INTERPRETATION
Heat stress caused by high ambient temperatures increases the risk of preterm birth in a geographical region with temperate climate. Prenatal routine care should be revised in such regions to provide active surveillance for women at risk.
FUNDING
Found in acknowledgements.
Topics: Pregnancy; Female; Infant, Newborn; Humans; Premature Birth; Retrospective Studies; Cohort Studies; Placental Circulation; Prospective Studies
PubMed: 37355458
DOI: 10.1016/j.ebiom.2023.104651 -
Seminars in Perinatology Dec 2017The mechanical integrity of the soft tissue structures supporting the fetus may play a role in maintaining a healthy pregnancy and triggering the onset of labor.... (Review)
Review
The mechanical integrity of the soft tissue structures supporting the fetus may play a role in maintaining a healthy pregnancy and triggering the onset of labor. Currently, the level of mechanical loading on the uterus, cervix, and fetal membranes during pregnancy is unknown, and it is hypothesized that the over-stretch of these tissues contributes to the premature onset of contractility, tissue remodeling, and membrane rupture, leading to preterm birth. The purpose of this review article is to introduce and discuss engineering analysis tools to evaluate and predict the mechanical loads on the uterus, cervix, and fetal membranes. Here we will explore the potential of using computational biomechanics and finite element analysis to study the causes of preterm birth and to develop a diagnostic tool that can predict gestational outcome. We will define engineering terms and identify the potential engineering variables that could be used to signal an abnormal pregnancy. We will discuss the translational ability of computational models for the better management of clinical patients. We will also discuss the process of model validation and the limitations of these models. We will explore how we can borrow from parallel engineering fields to push the boundary of patient care so that we can work toward eliminating preterm birth.
Topics: Biomechanical Phenomena; Cervix Uteri; Computer Simulation; Female; Fetal Membranes, Premature Rupture; Fetus; Finite Element Analysis; Humans; Imaging, Three-Dimensional; Magnetic Resonance Imaging; Models, Biological; Pregnancy; Premature Birth; Stress, Mechanical
PubMed: 28958628
DOI: 10.1053/j.semperi.2017.08.007 -
Fertility and Sterility Mar 2021
Topics: Female; Humans; Infant, Newborn; Pregnancy; Premature Birth
PubMed: 33712102
DOI: 10.1016/j.fertnstert.2021.01.021 -
Fertility and Sterility Mar 2013Biomarkers associated with spontaneous preterm birth and preeclampsia have been discovered in patients who experience these adverse obstetrical outcomes. The... (Review)
Review
Biomarkers associated with spontaneous preterm birth and preeclampsia have been discovered in patients who experience these adverse obstetrical outcomes. The identification of such biomarkers holds promise in both facilitating the early identification of those patients at greatest risk and enhancing our understanding of these disease processes to determine therapeutic interventions. To that end, our objective was to review the existing literature to determine the utility of biomarkers in the risk stratification of spontaneous preterm birth and preeclampsia. We found that despite the promise of some biomarkers in identifying patients at increased risk for spontaneous preterm birth and/or preeclampsia, the use of biomarkers in clinical practice to predict adverse obstetrical outcome remains challenging. Although data from small discovery studies may be encouraging, progress with biomarker research remains limited by the lack of validation of these discovered biomarkers. Furthermore, owing to the heterogeneity of existing studies, generalizable conclusions are difficult to understand, meta-analyses are challenging to perform, and agreement on cut-point standardization is difficult. The identification of an abnormal biomarker level does not guarantee whether or when an adverse clinical event might occur. Our lack of understanding of the true etiologies of these disease processes leaves us without definitive interventions to prevent spontaneous preterm birth and preeclampsia from occurring.
Topics: Abortion, Spontaneous; Biomarkers; Female; Gestational Age; Humans; Pre-Eclampsia; Pregnancy; Premature Birth; Risk Factors
PubMed: 23394778
DOI: 10.1016/j.fertnstert.2013.01.104 -
Journal of Global Health 2021Reducing preterm birth and stillbirth and improving outcomes for babies born too soon is essential to reduce under-5 mortality globally. In the context of a rapidly...
BACKGROUND
Reducing preterm birth and stillbirth and improving outcomes for babies born too soon is essential to reduce under-5 mortality globally. In the context of a rapidly evolving evidence base and problems with extrapolating efficacy data from high- to low-income settings, an assessment of the evidence for maternal and newborn interventions specific to low- and middle-income countries (LMICs) is required.
METHODS
A systematic review of the literature was done. We included all studies performed in LMICs since the Every Newborn Action Plan, between 2013 - 2018, which reported on interventions where the outcome assessed was reduction in preterm birth or stillbirth incidence and/or a reduction in preterm infant neonatal mortality. Evidence was categorised according to maternal or neonatal intervention groups and a narrative synthesis conducted.
RESULTS
179 studies (147 primary evidence studies and 32 systematic reviews) were identified in 82 LMICs. 81 studies reported on maternal interventions and 98 reported on neonatal interventions. Interventions in pregnant mothers which resulted in significant reductions in preterm birth and stillbirth were (i) multiple micronutrient supplementation and (ii) enhanced quality of antenatal care. Routine antenatal ultrasound in LMICs increased identification of fetal antenatal conditions but did not reduce stillbirth or preterm birth due to the absence of services to manage these diagnoses. Interventions in pre-term neonates which improved their survival included (i) feeding support including probiotics and (ii) thermal regulation. Improved provision of neonatal resuscitation did not improve pre-term mortality rates, highlighting the importance of post-resuscitation care. Community mobilisation, for example through community education packages, was found to be an effective way of delivering interventions.
CONCLUSIONS
Evidence supports the implementation of several low-cost interventions with the potential to deliver reductions in preterm birth and stillbirth and improve outcomes for preterm babies in LMICs. These, however, must be complemented by overall health systems strengthening to be effective. Quality improvement methodology and learning health systems approaches can provide important means of understanding and tackling implementation challenges within local contexts. Further pragmatic efficacy trials of interventions in LMICs are essential, particularly for interventions not previously tested in these contexts.
Topics: Developing Countries; Female; Humans; Infant; Infant, Newborn; Infant, Premature; Pregnancy; Premature Birth; Resuscitation; Stillbirth
PubMed: 35003711
DOI: 10.7189/jogh.11.04050 -
Clinical Obstetrics and Gynecology Sep 2014A multitude of pathophysiologic pathways culminate in the final common denominator of cervical softening, shortening, and dilation that lead to preterm birth. At... (Review)
Review
A multitude of pathophysiologic pathways culminate in the final common denominator of cervical softening, shortening, and dilation that lead to preterm birth. At present, a variety of emerging technology aims to objectively quantify critical cervical parameters such as microstructural organization and softening of the cervix. If the nature and timing of cervical changes can be precisely identified, it should be possible to identify the causative upstream molecular processes and resultant biomechanical events associated with each unique pathway. This would promote molecular studies, ultimately leading to novel approaches to preterm birth prediction, novel treatments, and prevention.
Topics: Cervical Ripening; Cervix Uteri; Female; Humans; Labor Stage, First; Pregnancy; Premature Birth; Ultrasonography, Prenatal
PubMed: 25084285
DOI: 10.1097/GRF.0000000000000049 -
International Journal of Environmental... Nov 2021Limited evidence is available on the safety and efficacy of antimicrobials during pregnancy, with even less according to the trimester of their use.
BACKGROUND
Limited evidence is available on the safety and efficacy of antimicrobials during pregnancy, with even less according to the trimester of their use.
OBJECTIVE
This study aimed to evaluate the association between exposure to antibiotics therapy (AT) during pregnancy and short-term neonatal outcomes.
METHODS
We considered 773,237 deliveries that occurred between 2007-2017 in the Lombardy region of Italy. We evaluated the risk of neonatal outcomes among infants that were born to mothers who underwent AT during pregnancy. The odds ratios and the hazard ratios, with the 95% confidence intervals, were estimated respectively for early (first/second trimester) and late (third trimester) exposure. The propensity score was used to account for potential confounders. We also performed subgroup analysis for the class of AT.
RESULTS
We identified 132,024 and 76,921 singletons that were exposed to AT during early and late pregnancy, respectively. Infants born to mothers with early exposure had 17, 11, and 16% increased risk of preterm birth, low birth weight, and low Apgar score, respectively. Infants that were exposed in late pregnancy had 25, 11, and 13% increased risk of preterm birth, low birth weight, and low Apgar score, respectively. The results were consistent in the subgroup analysis.
CONCLUSION
Our results suggested an increased risk of several neonatal outcomes in women exposed to ATs during pregnancy, albeit we were not able to assess to what extent the observed effects were due to the infection itself. To reduce the risk of neonatal outcomes, women that are prescribed AT during pregnancy should be closely monitored.
Topics: Anti-Bacterial Agents; Female; Humans; Infant; Infant, Low Birth Weight; Infant, Newborn; Pregnancy; Pregnancy Trimester, Second; Pregnancy Trimester, Third; Premature Birth
PubMed: 34886350
DOI: 10.3390/ijerph182312621 -
Deutsches Arzteblatt International Dec 2019The preterm birth rate in Germany has remained unchanged at 8-9% since 2009. Preterm birth is the most common cause of neonatal morbidity and mortality. In the absence... (Review)
Review
BACKGROUND
The preterm birth rate in Germany has remained unchanged at 8-9% since 2009. Preterm birth is the most common cause of neonatal morbidity and mortality. In the absence of a causal treatment, it is important to lower the risk of preterm birth by preventive measures in prenatal outpatient care.
METHODS
This review is based on pertinent publications from the years 2000-2019 that were retrieved by a selective search in PubMed.
RESULTS
The clinical risk factors for preterm birth-known mainly from retrospective cohort studies-include previous preterm birth (adjusted odds ratio [aOR]: 3.6), multiple pregnancy (relative risk [RR]: 7.7), nicotine consumption (aOR: 1.7), and a short uterine cervix, i.e., <25 mm in the second trimester (aOR: 6.9). In women with a short cervix, vaginally administered progesterone significantly lowers the preterm birth rate (22.5% vs. 14.1% for birth before 33 weeks of gestation, RR: 0.62; 95% confidence interval [0.47; 0.81]). Nicotine abstinence is associated with a lower pre- term birth rate as well (aOR: 0.91; [0.88; 0,.94]), while working more than 40 hours per week (aOR: 1.25; [1,.01; 1,.54]) and heavy lifting during pregnancy (hazard ratio [HR]: 1.43; [1.13; 1.80]) are associated with a higher preterm birth rate. Avoidance of physical exertion, or bed rest, in the face of impending preterm birth does not lower the preterm birth rate, but it does increase the risk of complications, such as thromboembolism.
CONCLUSION
The meticulous assessment and elimination of treatable risk factors at the outset of ambulatory prenatal care can help lower the preterm birth rate. Further velopment of causally directed treat- ments (e.g., changes of relevant environmental and epigenetic factors).
Topics: Ambulatory Care; Female; Germany; Humans; Pregnancy; Premature Birth; Prenatal Care; Retrospective Studies; Risk Factors
PubMed: 31931955
DOI: 10.3238/arztebl.2019.0858