Trisomy 21 (T21), trisomy 18 (T18) and trisomy 13 (T13) represent the most common autosomal trisomies detected in live-born infants. Previous studies have addressed interventions, morbidities and survival in term or near-term infants with T21, T18 or T13, or were limited by a small number of patients. However, the combination of one of these chromosomal anomalies and very low birth weight (VLBW) presents greater challenges. Data from the NICHD Neonatal Research Network (NRN) and from the Vermont Oxford Network (VON) databases were used to examine the frequency, interventions, risk of mortality and neonatal morbidities, including patent ductus arteriosus (PDA), necrotizing enterocolitis (NEC), late onset sepsis (LOS), retinopathy of prematurity (ROP), and bronchopulmonary dysplasia (BPD), among VLBW infants with T21, T18 or T13 compared to VLBW infants without major birth defects (BD) and VLBW infants with non-chromosomal BD. Anthropometric VON charts for the assessment of birth weight for gestational age among 22 week to term infants with T21, T18 or T13 were also developed. In the VON database (n=539,509), the frequency of VLBW infants diagnosed with T21 was 1681 (0.31%), with T18 was 1416 (0.27%), and with T13 was 435 (0.08%). Major surgery was reported for 30.4% of infants with T21, 9.2% with T18, and 6.8% with T13. In-hospital mortality occurred for 33.1% of infants with T21, 89.0% with T18, and 92.4% with T13. Median survival time was 4 days (95% CI: 3-4) among infants with T18 and 3 days (95% CI: 2-4) among infants with T13. Birth weight for gestational age charts were created using VON data with a total of 5147 infants with T21 aged 22-41 weeks, 1053 infants with T18 aged 22-41 weeks, and 613 infants with T13 aged 22-40 weeks. Among the three groups, infants with T18 were the most likely to be growth restricted while infants with T21 were the least likely to be growth restricted. The new anthropometric VON charts for infants with T21 were also compared to the Lubchenco and Fenton charts and both showed frequent misclassification of infants with T21 as small or large for gestational age. In the NICHD NRN database (n=52,259), 133 (0.26%) VLBW infants were diagnosed with T21, 132 (0.25%) with T18 and 40 (0.08%) with T13. The adjusted relative risk, estimated using Poisson regression models with robust variance estimators, showed an increased risk of death, PDA, NEC, LOS, and BPD among infants with T21 relative to infants with no BD. Relative to infants with non-chromosomal BD, infants with T21 were at increased risk of PDA and NEC. A trend toward a lower risk of ROP was observed among infants with T21 compared to infants with non-chromosomal BD and infants without major BD. Infants with T13, but not infants with T18, were less likely to be mechanically ventilated than infants with T21 and infants without BD. Infants with T18 had increased risk of PDA compared to infants with T13, infants with T21 and infants without BD and increased risk of BPD compared to infants with T21 and infants without BD. The current studies evaluated the largest cohorts of VLBW infants with T21, T18 or T13. These data are important to help families and care providers make informed decisions involving the care of their VLBW infants with these chromosomal anomalies.

The neonate is still at risk of acquiring Group B Streptococcus (GBS) infection upon delivery even with the implementation of early onset GBS neonatal disease preventative protocols. GBS was reported as the most prevalent organism causing neonatal morbidity and mortality in the USA and Australia in the 1990s. GBS is also known to cause disease in children, women, the immunocompromised adult and the elderly, but it is the preterm neonates who are at greatest risk of GBS neonatal disease. The aim of this study was to determine the prevalence of lower genital tract (LGT) colonisation with GBS in Brisbane women of child bearing age. We also aimed: (i) to compare the GBS LGT prevalence rate of Indigenous and non Indigenous women; (ii) to determine whether previously reported risk factors for LGT colonisation with GBS were also risk factors associated with GBS colonisation of women in this study; (iii) to further develop and optimise a rapid PCR assay that could detect maternal LGT GBS colonisation; and (iv) to serotype the GBS strains that were isolated from pregnant and non pregnant women who participated in this study. This study recruited 374 women of childbearing age attending public medical providers and found an overall GBS prevalence of 98/374 (26.2%) for these Brisbane women, a rate higher than previously reported in Australia. When the GBS prevalence for pregnant women (25.6%) was compared to non pregnant women (27.2%) they were similar. We also compared the GBS LGT colonisation rate of women attending different medical providers. The GBS LGT prevalence rate for pregnant women attending the Mater was 36/118 (30.5%), whilst those women attending the Redlands Hospital antenatal clinic had a LGT GBS prevalence rate of only 7/53 (13.2%). By comparison, the LGT GBS prevalence rate for non pregnant women attending Biala Sexual Health clinic was 21/69 (30.4%) and 34/127 (26.8%) of women attending the Brisbane Family Planning Queensland were also GBS positive. The seven women recruited from Inala community centre tested negative for GBS LGT colonisation. The LGT GBS prevalence of Australian Aboriginal women was 5/22 (22.7%), a rate which was not significantly different from non-Aboriginal women 78/288 (27.1%). Established early onset GBS neonatal disease preventative policies have been recently revised. The CDC now recommends that all pregnant women are screened for LGT GBS colonisation during late gestation, and that any GBS isolates be tested for resistance to antibiotics if the GBS positive women have an allergy to penicillin. Queensland's Department of Health recommend that Queensland medical agencies implement a non screening based preventative protocol, where clinicians monitor: women prior to labour for reported risk factors associated with maternal GBS colonisation: women in labour for 'obstetric risk factors'. A number of risk factors have previously been reported in association with GBS LGT colonisation. However, in this current study we found that only one risk factor was significantly associated with current GBS: previous reported LGT GBS colonisation was significantly associated with maternal LGT GBS colonisation reported in this study. Women who previously tested positive for GBS were significantly more likely to be GBS positive in subsequent tests (OR 4.7; 95%CI, 1.8-12.5) compared to women with no previous history of GBS colonisation. An assessment of adverse pregnancy outcomes, preterm deliveries, and GBS colonisation data was made. It was established that 30 women had previously given birth to one or more preterm neonates and of these 30 women, nine (30%) of them tested positive for GBS in this current study. Of the 71 women who had given birth to neonates and who had suffered an adverse pregnancy outcome 25.3% also tested positive for GBS in this current study. GBS was identified in up to 30% of all mothers who had delivered their neonate preterm, 27.4% of women who had previously suffered miscarriages and 16.7% of women who had previously had stillbirths. In this study we found that Australian Aboriginal women also had a greater risk of delivering neonates who suffered from an adverse pregnancy outcome in comparison to all other women. Twenty one of the 22 Aboriginal women had previously been pregnant at least once, and nine (42.9%) of these women had at least one prior adverse pregnancy outcome while seven (33.3%) of these women had previously delivered at least one neonate preterm. Of the 21 Aboriginal women who had a previous pregnancy more than half the total number of Aboriginal women (11/21) had either delivered one or more neonates preterm or had suffered from one or more adverse pregnancy outcomes. When the incidence of adverse pregnancy outcomes was compared for Aboriginal and all other women the results were surprising. Overall, this study found 216 women including Aboriginal women had previously been pregnant and of these women 71 (32.8%) of them suffered an adverse pregnancy outcome. By comparison, only 62 of 195 (31.8%) non Aboriginal women but nine out of 21 (41.9%) Australian Aboriginal women suffered from a previous adverse pregnancy outcome. The clinical LGT GBS isolates found in this study of Brisbane women were typed and all nine GBS serotypes plus non typeable GBS serotypes were detected. Seventy women tested GBS culture positive and vaginal and/or perianal samples obtained from these women were evaluated. GBS serotype III was the serotype most frequently isolated from this total population, from 47.4% of pregnant women and 51.7% of non pregnant women. From some women only a single GBS serotype was isolated: in these women we found that GBS serotype III (50%) was the predominant isolate, followed by GBS serotype Ia isolated from 16.7% women. In addition 4.2% of women were colonised with GBS serotypes; Ib, II and V, whilst GBS serotypes IV and VII were isolated from 2.1% women. Non typeable GBS strains confirmed by latex agglutination tests accounted for 11.9% of all strains isolated from these Brisbane women. This study identified multiple serovars in 15 clinical samples and found that 22 (31.4%) women were colonised with mixed GBS serotypes in samples collected from both vaginal and perianal regions. In five women the combination of serotypes III/Ia were identified and in other women combinations of serotypes III/II, III/IV, III/V, III/VIII, Ia/IV and Ib/NT were also detected. In two instances three serotype combinations were detected in samples from one woman and these included serotypes III/Ib/II and III/Ia/Ib. Isolates were also typed for women who were colonised in both vaginal and perianal regions and it was found that only 10 participants had identical isolates in both regions. GBS serotype III was the predominant serotype detected in women tested in this study and this is the serotype that has previously been associated with invasive infections in neonates. GBS neonatal disease is a world wide economic, health and social burden affecting different ethnic groups and is preventable. Currently no vaccine technology is available for the prevention of GBS neonatal disease and the most effective EOGND preventative protocol would be to test for maternal GBS colonisation during labour, or screen women for GBS at &gt36 weeks' gestation and administer intrapartum antibiotic prophylaxis (IAP) to all women who tested positive for GBS. In this current study we utilised a rapid bsp PCR assay to detect LGT GBS colonisation in women of child bearing age. The PCR assay identified 62.5% of all vaginal and perianal positive culture GBS samples. The specificity of the PCR assay was 89% while the positive and negative predictive values were 56.8% and 91.1% respectively. This PCR assay using the current parameters is not an effective GBS detection assay but could be further optimised in the near future. This PCR assay could be an effective test in the future with the development of an alternative DNA extraction method to InstaGene (BioRad). However, this PCR assay if used in conjunction with the current culture method is able to detect a further 8.9% of women colonised with asymptomatic GBS. Brisbane women aged between 26 to 35 years who are pregnant and who are attending public health care agencies are at greatest risk of being colonised with GBS. No disparity was identified when ethnicity or social standing were assessed. The overall results of this study demonstrate that the LGT GBS prevalence rate in Brisbane women is 26.2% but this rate was higher at 30.5% for women attending a Brisbane sexual health clinic and for pregnant women attending the Mater Mothers' antenatal clinic. GBS serovar III has been identified as the dominant serovar in our population group and this strain has been reported as the major cause of GBS disease in neonates and infants aged to three months. Disparity (11.1%) was reported when the incidence of adverse pregnancy outcomes amongst Aboriginal women was compared to non Aboriginal women. From the outcomes of this study it has been suggested that Queensland adopt a screening based GBS preventative protocol. It has also been suggested that an Australian wide GBS prevention strategy may further reduce the incidence of neonatal disease.

Made available in DSpace on 2014-07-22T13:14:48Z (GMT). No. of bitstreams: 2 Paula Coelho.pdf: 741288 bytes, checksum: e8d1b8f480ab01982538dd474c9291b4 (MD5) license.txt: 1914 bytes, checksum: 7d48279ffeed55da8dfe2f8e81f3b81f (MD5) Previous issue date: 2011 / Fundação Oswaldo Cruz. Instituto Fernandes Figueira. Departamento de Ensino. Programa de Pós-Graduação em Saúde da Criança e da Mulher. Rio de Janeiro, RJ, Brasil. / Objetivos: O presente estudo teve como objetivo analisar aspectos maternos, obstétricos e perinatais da gestação gemelar em população assistida em unidade terciária do Rio de Janeiro, estabelecendo o perfil da gestação gemelar, identificando os eventuais danos relacionados à morbimortalidade perinatal do segundo gemelar, tendo como referencia o que nasceu primeiro e as principais morbidades determinantes da morbimortalidade neonatal dos gêmeos, independentemente da localização na cavidade uterina. Metodologia: Através de estudo de coorte, de caráter retrospectivo, foram analisados prontuários de 613 gestações gemelares do Instituto Fernandes Figueira/ Fundação Oswaldo Cruz no período de janeiro de 1993 a dezembro de 2007. Participaram do estudo gestações exclusivamente duplas, cujas pré-natais e partos foram integralizados na instituição. Resultados: A prevalência da gemelidade no período estudado foi de 4,0%. Dentre as principais intercorrências maternas destacaram-se a anemia (47,8%), trabalho de parto prematuro (39,1%), síndromes hipertensivas (25,5%) e rotura prematura das membranas (18,2%). Na população estudada a operação cesariana foi quase sempre eleita como via de parto preferencial (74,4%). A principal morbidade neonatal foi a prematuridade, que atingiu 66,1% dos conceptos. Um significativo contingente de recém-nascidos apresentou intercorrências no período neonatal (65,3%), sendo as condições mais prevalentes: alterações respiratórias (29,2%), metabólicas (27,7%), infecciosas (27,3%) e hematológicas (19,3%). Quanto aos danos relacionados ao segundo gemelar, não se observou, no geral, diferença estatisticamente significativa quando comparado com o primeiro na maioria dos desfechos elegíveis, exceto o baixo peso ao nascer, índices de Apgar inferior a sete no quinto minuto de vida, além de intercorrências hematológicas e nutricionais. No que tange ao determinismo da mortalidade neonatal na gestação gemelar, chama atenção que a condução do parto por via vaginal nos recém-nascidos com peso abaixo de 2500g, as apresentações não cefálicas, o baixo peso ao nascer, os baixos índices de Apagar e as morbidades neonatais se mostraram como fatores determinantes da mortalidade neonatal em qualquer um dos produtos da concepção, independentemente da localização intra-uterina. Conclusões: Dada a alta prevalência de resultados ominosos para o binômio, especialmente a prematuridade e complicações obstétricas, ressalta-se a importância de referenciar casos de gestação gemelar para unidade terciária. Os resultados neonatais indicam tendência dos gemelares em apresentarem complicações, não sendo demonstrado pelo presente estudo o pior prognóstico do segundo gemelar. / Objectives: This study aimed to examine aspects of maternal, obstetric and perinatal outcomes of twin pregnancy in a population assisted at a tertiary center in Rio de Janeiro, establishing the profile of the twin pregnancy, identifying the damage related to perinatal morbidity and mortality of the second twin, with the references the first born and the main determinants of morbidity and neonatal mortality and morbidity of twins, regardless of location in the uterine cavity. Methodology: Through a retrospective, cohort study, 613 twin pregnancies from Instituto Fernandes Figueira were analyzed from january 1993 to december 2007. The study included only twin pregnancies, whose prenatal care and delivery were conducted into the institution. Results: The prevalence of twin pregnancy during the study period was 4.0%. The major contributors to maternal problems were anemia (47.8%), preterm labor (39.1%), hypertensive disorders (25.5%) and premature rupture of membranes (18.2%). In these situations the caesarean section was almost always chosen as the preferred mode of delivery (74.4%). The major neonatal morbidity was prematurity, which reached 66.1% of fetuses. A significant number of newborns had complications in the neonatal period (65.3%), being the most prevalent conditions: respiratory disorders (29.2%), metabolic (27.7%), infection (27.3%) and hematologic (19.3%). Concerning the demages related to the second twin, it wasn’t found in general, statistically significant difference compared to its co-twin in most outcomes, except for low birth weight, Apgar score below seven, hematological and nutritional complications. Regarding the determinism of neonatal mortality in twin pregnancy what draws attention is the fact that: vaginal delivery, non-cephalic presentations, low birth weight, low Apgar scores and neonatal morbidities were shown as determinants of neonatal mortality in any of the products of conception, regardless of the location in the uterus Conclusion: Given the high prevalence of ominous results for the pair, especially prematurity and obstetric complications, the study highlights the importance of referring cases of twin pregnancy to tertiary hospitals. Neonatal results indicate the tendency in twins to undergo complications, the worse.

A Casa do Parto de Sapopemba (CPS) é uma unidade autônoma, isolada do hospital, integrada ao Sistema Único de Saúde. Atende mulheres com gestação de baixo risco e a assistência é prestada exclusivamente por obstetrizes e enfermeiras obstétricas. Este modelo tem sido criticado em relação à segurança para a mulher e recém-nascido. A literatura aponta menos intervenções desnecessárias e maiores níveis de satisfação das mulheres atendidas em casas de parto. No Brasil existem poucos estudos sobre o tema. Os objetivos deste estudo, do tipo caso-controle, foram: descrever as remoções neonatais segundo o motivo, tempo de vida, local e desfecho; identificar os fatores de risco associados à remoção. Ocorreram 2.840 partos na CPS no período de setembro de 1998 a agosto de 2005. Os casos foram todos os recém-nascidos removidos da CPS para hospitais de referência (n=32) no período do estudo. Os controles foram recém-nascidos da CPS, nascidos no mesmo período e que não foram removidos (n=64). Os dados foram coletados dos prontuários e registro sobre os partos da instituição. Foi realizada análise univariada e de regressão logística múltipla dos dados. A prevalência de remoções e a taxa de mortalidade neonatal foi de 1,1% e 1/1.000 nascidos vivos, respectivamente. O desconforto respiratório foi o motivo principal para a remoção neonatal seguido de suspeita de aspiração de mecônio, hipotonia e asfixia neonatal. O Hospital Geral de Vila Alpina recebeu 51,6 % das remoções e o Amparo Maternal 32,6%. No momento da remoção, o tempo de vida do recém-nascido variou entre 5 minutos e 30 horas (média=8 horas; mediana=5 horas; dp=8,3 horas). Os fatores de risco para remoção neonatal foram: intercorrências no trabalho de parto e parto (OR=5,5; IC 95% 1,06 – 28,26), hábito de fumar durante a gestação (OR=4,1; IC 95% 1,03 – 16,33) e Índice de Apgar igual ou menor que sete no primeiro minuto de vida (OR=7,8; IC 95% 1,62 – 37,03). As taxas de remoção e mortalidade neonatal encontradas, similares ou inferiores a estudos internacionais, são importantes indicadores da qualidade do atendimento na CPS. Acredita-se que o conhecimento dos fatores de risco para remoção possa contribuir para o aprimoramento da assistência, pela identificação de situações que apontam para um maior risco de complicações neonatais. / The Sapopemba Birth Center (SBC) is a public free-standing maternity unit, isolated from the reference hospital. Obstetric care for low-risk women is offered by midwives and nurse-midwives. This model of care has been questioned concerning women and newborns safety. Studies show less unnecessary interventions and higher level of satisfaction of women assisted in birth centers. There are few studies on this subject in Brazil. This case-control study aimed to: describe neonatal transfers according to the reasons, newborn lifetime, backup hospital and conditions of newborns after transfer; identify risk factors associated with neonatal transfers in this setting. There were 2,840 births in the SBC during the study period, from September 1998 to August 2005. Cases were all newborns transferred from the SBC to referenced hospitals (32) during the study period. Controls were selected from newborns delivered at the SBC in the same period and who were not transferred to hospital (64). Data were collected from records available at the birth center. Unvaried and multiple analysis was performed using conditional logistic regression. The neonatal transfer and mortality rates were 1.1% and 1/1,000, respectively. Respiratory distress was the main reason for transfer, followed by suspected aspiration of meconium, hypotonia and neonatal asphyxia. The Vila Alpina General Hospital received 51.6% of transfers from the SBC and the Amparo Maternal, 32.6%. In the moment of transfer, the newborn’s lifetime varied from 5 minutes to 30 hours (mean = 8 hours; median = 5 hours; sd = 8,3 hours). Risk factors associated with neonatal transfers were: labor and intrapartum complications (OR = 5.5; CI 95% 1.06 – 28.26); smoking during pregnancy (OR = 4.1; CI 95% 1.03 – 16.33); first minute Apgar score bellow eight (OR = 7.8; CI 95% 1.62 – 37.03). Neonatal mortality and transfer rates found in this study were similar or lower comparing to the international studies and they represent an important index of quality related to the assistance given in the SBC. The knowledge of risk factors associated with neonatal transfers from this birth center may contribute for the improvement of care, by the identification of the situations that show a higher risk of neonatal complications.

Research report (MMed) -- Stellenbosch University, 2010. / Bibliography / ENGLISH ABSTRACT: BACKGROUND: Hypertension and its complications is responsible for a significant proportion of maternal and neonatal morbidity and mortality worldwide. In Dora Nginza Hospital, clinical experience has shown that hypertension and its complications are common but despite this assumption, the overall prevalence of complications, social and demographic characteristics and various forms of presentations of hypertension in pregnancy is still largely unknown. OBJECTIVES: To determine the prevalence of complications, risk factors, social and demographic characteristics of hypertensive complications of pregnancy in Dora Nginza Hospital. STUDY DESIGN: The study is a retrospective descriptive study performed on medical records. The study was carried out by looking at records of patients admitted with hypertension in pregnancy over a 2 year period (2007-2008). MS Excel was used to capture the data and STATISTICA version 9 was used for data analysis. SETTING: Dora Nginza hospital, Port Elizabeth Hospitals Complex. MAIN OUTCOME MEASURES: The incidence, risk factors, maternal complications, perinatal outcome. RESULTS: A total of 22,711 deliveries were recorded in Dora Nginza hospital over the two year period (2007-2008). 1520 cases were complicated by hypertension giving an incidence of hypertension as 6.69% (66.9 per 1000 deliveries). The incidence of pre eclampsia is 35.40% and chronic hypertension 2.80%. Maternal complications occurred in 40.29% of the hypertensive women. Maternal deaths occurred in 0.79% (790 per 100000 deliveries) accounting for 38.71% of the total maternal deaths in the facility. Poor neonatal outcome was recorded in 5.90% of these women. The 2.30% stillbirths represent 3.30% of all fetal deaths in the facility for the study period. Prominent risk factors are age, race, low socioeconomic status, smoking and BMI CONCLUSION: Hypertensive disorders of pregnancy in Dora Nginza hospital is common and is an important cause of maternal and perinatal morbidity and mortality. Improved socioeconomic status, quality obstetric services which include early booking, proper antenatal care, early referral and proper documentation can minimise the effect of hypertension on pregnancy. / AFRIKAANSE OPSOMMING: geen opsomming

A Casa do Parto de Sapopemba (CPS) é uma unidade autônoma, isolada do hospital, integrada ao Sistema Único de Saúde. Atende mulheres com gestação de baixo risco e a assistência é prestada exclusivamente por obstetrizes e enfermeiras obstétricas. Este modelo tem sido criticado em relação à segurança para a mulher e recém-nascido. A literatura aponta menos intervenções desnecessárias e maiores níveis de satisfação das mulheres atendidas em casas de parto. No Brasil existem poucos estudos sobre o tema. Os objetivos deste estudo, do tipo caso-controle, foram: descrever as remoções neonatais segundo o motivo, tempo de vida, local e desfecho; identificar os fatores de risco associados à remoção. Ocorreram 2.840 partos na CPS no período de setembro de 1998 a agosto de 2005. Os casos foram todos os recém-nascidos removidos da CPS para hospitais de referência (n=32) no período do estudo. Os controles foram recém-nascidos da CPS, nascidos no mesmo período e que não foram removidos (n=64). Os dados foram coletados dos prontuários e registro sobre os partos da instituição. Foi realizada análise univariada e de regressão logística múltipla dos dados. A prevalência de remoções e a taxa de mortalidade neonatal foi de 1,1% e 1/1.000 nascidos vivos, respectivamente. O desconforto respiratório foi o motivo principal para a remoção neonatal seguido de suspeita de aspiração de mecônio, hipotonia e asfixia neonatal. O Hospital Geral de Vila Alpina recebeu 51,6 % das remoções e o Amparo Maternal 32,6%. No momento da remoção, o tempo de vida do recém-nascido variou entre 5 minutos e 30 horas (média=8 horas; mediana=5 horas; dp=8,3 horas). Os fatores de risco para remoção neonatal foram: intercorrências no trabalho de parto e parto (OR=5,5; IC 95% 1,06 – 28,26), hábito de fumar durante a gestação (OR=4,1; IC 95% 1,03 – 16,33) e Índice de Apgar igual ou menor que sete no primeiro minuto de vida (OR=7,8; IC 95% 1,62 – 37,03). As taxas de remoção e mortalidade neonatal encontradas, similares ou inferiores a estudos internacionais, são importantes indicadores da qualidade do atendimento na CPS. Acredita-se que o conhecimento dos fatores de risco para remoção possa contribuir para o aprimoramento da assistência, pela identificação de situações que apontam para um maior risco de complicações neonatais. / The Sapopemba Birth Center (SBC) is a public free-standing maternity unit, isolated from the reference hospital. Obstetric care for low-risk women is offered by midwives and nurse-midwives. This model of care has been questioned concerning women and newborns safety. Studies show less unnecessary interventions and higher level of satisfaction of women assisted in birth centers. There are few studies on this subject in Brazil. This case-control study aimed to: describe neonatal transfers according to the reasons, newborn lifetime, backup hospital and conditions of newborns after transfer; identify risk factors associated with neonatal transfers in this setting. There were 2,840 births in the SBC during the study period, from September 1998 to August 2005. Cases were all newborns transferred from the SBC to referenced hospitals (32) during the study period. Controls were selected from newborns delivered at the SBC in the same period and who were not transferred to hospital (64). Data were collected from records available at the birth center. Unvaried and multiple analysis was performed using conditional logistic regression. The neonatal transfer and mortality rates were 1.1% and 1/1,000, respectively. Respiratory distress was the main reason for transfer, followed by suspected aspiration of meconium, hypotonia and neonatal asphyxia. The Vila Alpina General Hospital received 51.6% of transfers from the SBC and the Amparo Maternal, 32.6%. In the moment of transfer, the newborn’s lifetime varied from 5 minutes to 30 hours (mean = 8 hours; median = 5 hours; sd = 8,3 hours). Risk factors associated with neonatal transfers were: labor and intrapartum complications (OR = 5.5; CI 95% 1.06 – 28.26); smoking during pregnancy (OR = 4.1; CI 95% 1.03 – 16.33); first minute Apgar score bellow eight (OR = 7.8; CI 95% 1.62 – 37.03). Neonatal mortality and transfer rates found in this study were similar or lower comparing to the international studies and they represent an important index of quality related to the assistance given in the SBC. The knowledge of risk factors associated with neonatal transfers from this birth center may contribute for the improvement of care, by the identification of the situations that show a higher risk of neonatal complications.

A quantitative descriptive, retrospective and cross-sectional study was conducted. The purpose of the study was to identify and describe factors that contributed to high sickness and death rate of babies admitted in the Neonatal Unit at a tertiary institution in Limpopo Province. Data were collected from the patient’s records by administering an auditing tool. The tool included initial assessment on antenatal care, intra-partum and neonatal care. Analysis of data was performed by IBM Statistical Package for Social Sciences (SPSS) Statistics 22 computer software version. Frequency tables and pie graphs were used to present the data. The findings revealed that 42% of the mothers whose babies were admitted in the Neonatal Unit were in their childbearing period, 71% of the mothers started antenatal care at the second trimester and 75% babies were admitted within the first six hours of life. Respiratory distress, 77% and prematurity, 43% were the common conditions for admission in the Neonatal Unit. Spontaneous preterm and immaturity were the common causes of death. Recommendations are that education and training on record keeping to be done on continuous basis, to conduct quality improvement programmes and implement maternal and neonatal guidelines in the clinical area throughout. / Health Studies / M.A. (Health Studies)

A quantitative descriptive, retrospective and cross-sectional study was conducted. The purpose of the study was to identify and describe factors that contributed to high sickness and death rate of babies admitted in the Neonatal Unit at a tertiary institution in Limpopo Province. Data were collected from the patient’s records by administering an auditing tool. The tool included initial assessment on antenatal care, intra-partum and neonatal care. Analysis of data was performed by IBM Statistical Package for Social Sciences (SPSS) Statistics 22 computer software version. Frequency tables and pie graphs were used to present the data. The findings revealed that 42% of the mothers whose babies were admitted in the Neonatal Unit were in their childbearing period, 71% of the mothers started antenatal care at the second trimester and 75% babies were admitted within the first six hours of life. Respiratory distress, 77% and prematurity, 43% were the common conditions for admission in the Neonatal Unit. Spontaneous preterm and immaturity were the common causes of death. Recommendations are that education and training on record keeping to be done on continuous basis, to conduct quality improvement programmes and implement maternal and neonatal guidelines in the clinical area throughout. / Health Studies / M. A. (Health Studies)

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Contexte: Le retard de croissance intra-utérin (RCIU) désigne l’incapacité du fœtus à atteindre son potentiel de croissance déterminé génétiquement en raison de diverses causes. Il est défini le plus souvent par un poids de naissance inférieur au 10ème percentile pour l’âge gestationnel sur les courbes néonatales. Ce travail de thèse a comme objectif de répondre aux questions non-résolues sur la définition et les conséquences du RCIU dans le contexte de la grande prématurité: (1) Quelle est la meilleure définition du RCIU à utiliser pour identifier les enfants à risque ? (2) Quels sont les risques de mortalité et de morbidités néonatales respiratoires et neurologiques associés au RCIU et existe-t-il des interactions avec les pathologies de la grossesse responsables de cette naissance très prématurée ? (3) Quel est l’impact du RCIU sur le devenir neuro-développemental à 2 ans, en particulier chez les enfants nés extrêmement prématurément ? Méthodes: Nous avons utilisé deux sources de données. L’étude MOSAIC (Models for OrganiSing Access to Intensive Care for Very Preterm Babies in Europe) est une étude européenne en population qui porte sur l’ensemble des naissances survenues entre 22 et 31 semaines d’aménorrhée en 2003 dans dix régions européennes. Les enfants ont été suivis jusqu’à la sortie d’hospitalisation (population d’étude : 4525 enfants). La deuxième source est une cohorte d’enfants nés avant 27SA qui ont été hospitalisés dans le service de réanimation néonatale à l'hôpital de Port-Royal de 1999 à 2008 et qui ont eu un examen pédiatrique et une évaluation selon l’échelle de Brunet-Lézine qui inclut quatre domaines du développement global de l’enfant : la motricité globale, la motricité fine, le langage et l’interaction sociale (445 enfants admis, 268 enfants suivis à 2 ans). Résultats: Dans les deux populations, les risques de décès et de dysplasie broncho-pulmonaire étaient plus élevés pour les enfants ayant un poids de naissance <10éme percentile des courbes néonatales, mais également pour des enfants avec un poids plus élevé (entre le 10éme et le 24éme percentile des courbes néonatales ou <10ème percentile des courbes fœtales). Par contre, il n’y avait pas de lien entre les complications neurologiques et le faible poids, ni d’interaction avec les pathologies de la grossesse. Le RCIU était associé à un risque élevé du retard neurocognitif à deux ans d’âge corrigé chez les extrêmes prématurés, surtout dans le domaine de la motricité fine et de l’interaction sociale mais pas dans le domaine du langage et de la motricité globale. Nous n’avons pas trouvé d’association entre le RCIU et le risque d’infirmité motrice cérébrale à deux ans d’âge corrigé. Conclusions: L’utilisation du 10ème percentile des courbes néonatales n’est pas adaptée pour identifier l’impact du RCIU chez les grands prématurés ; l’utilisation de multiples seuils ou de courbes de croissance fœtale est nécessaire. Le RCIU accroit les risques de mortalité et de dysplasie broncho-pulmonaire, mais n’est pas associé aux lésions cérébrales sévères ; ces associations sont observées dans différents contextes périnatals (pathologies vasculaires et infectieuses, et naissances à des âges gestationnels très précoces). Le RCIU représente un facteur pronostic défavorable pour le neuro-développement à moyen terme. Nos résultats soulèvent de nouvelles questions sur le suivi adapté pour les enfants ayant un RCIU après leur sortie de l’hôpital et aussi sur les éventuels mécanismes biologiques pouvant expliquer les liens entre le RCIU avec une morbidité respiratoire et certains domaines du développement neurocognitif à moyen terme. / Background: Intrauterine growth restriction (IUGR) refers to the inability of the fetus to achieve its genetically determined growth potential due to various causes. Most often, it is defined by a birth weight less than the 10th percentile for gestational age using neonatal growth curves. This thesis aims to answer unresolved questions about the definition and consequences of IUGR in the context of very preterm birth: (1) what is the best definition of IUGR for identifying children at risk? (2) What are the risks of mortality and neonatal respiratory and neurological morbidity associated with IUGR and are there interactions with the underlying pregnancy complications responsible for the very preterm birth? (3) What is the impact of IUGR on neurodevelopmental at 2 years, especially for children born extremely preterm ? Methods: We used two data sources. The MOSAIC study (Models for Organising Access to Intensive Care for Very Preterm Babies in Europe) is a European population-based study that included all births occurring between 22 and 31 weeks of gestation in 2003 in ten European regions. The children were followed until hospital discharge (study population = 4525 infants). The second source is a cohort of children born before 27 weeks of GA who were hospitalized in the neonatal intensive care unit at the Port Royal Hospital from 1999 to 2008 and had a pediatric examination and Brunet-Lézine (BL) neurodevelopmental assessment at 2 years of corrected age (445 children in the cohort, 268children followed at 2 years). The BL assessment includes four areas of child development: gross motor, fine motor, language and social interaction skills. Results: In both populations, the risk of death and bronchopulmonary dysplasia were higher for children with a birth weight <10th percentile of neonatal growth curves but also for children with a higher birth weight (between the 10th and the 24th percentile of neonatal growth curves or <10th percentile of fetal growth curves). In contrast, there was no link between neurological complications and low birth weight and no interactions with pregnancy complications. IUGR was associated with neurocognitive delay among extremely preterm children evaluated at two years of corrected age, especially for fine motor and social interaction skills, but not for language and gross motor skills. We did not find any association between IUGR and the risk of cerebral palsy at two years of corrected age. Conclusions: The use of the 10th percentile of neonatal growth curves is not suitable for identifying the impact of IUGR in very preterm infants; using higher thresholds or fetal growth curves is necessary. IUGR increased the risks of mortality and bronchopulmonary dysplasia, but was not associated with severe brain damage; these associations are observed in multiple clinical contexts (vascular and infectious pregnancy complications, and births at very early gestational ages). IUGR is a risk factor for poor medium-term neuro-development. Our results raise new questions about the appropriate surveillance for children with IUGR after discharge from the hospital and also about possible biological mechanisms that could explain the relationship between IUGR and respiratory morbidity and neurocognitive development.