Working in pediatric and neonatal intensive care units (ICUs) can be challenging and differs from work in adult ICUs. This study investigated for the first time the perceptions, experiences and ...challenges that healthcare professionals face when dealing with end-of-life decisions in neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs) in Croatia.
This qualitative study with focus groups was conducted among physicians and nurses working in NICUs and PICUs in five healthcare institutions (three pediatric intensive care units (PICUs) and five neonatal intensive care units (NICUs)) at the tertiary level of healthcare in the Republic of Croatia, in Zagreb, Rijeka and Split. A total of 20 physicians and 21 nurses participated in eight focus groups. The questions concerned everyday practices in end-of-life decision-making and their connection with interpersonal relationships between physicians, nurses, patients and their families. The constant comparative analysis method was used in the analysis of the data.
The analysis revealed two main themes that were the same among the professional groups as well as in both NICU and PICU units. The theme "critical illness" consisted of the following subthemes: the child, the family, myself and other professionals. The theme "end-of-life procedures" consisted of the following subthemes: breaking point, decision-making, end-of-life procedures, "spill-over" and the four walls of the ICU. The perceptions and experiences of end-of-life issues among nurses and physicians working in NICUs and PICUs share multiple common characteristics. The high variability in end-of-life procedures applied and various difficulties experienced during shared decision-making processes were observed.
There is a need for further research in order to develop clinical and professional guidelines that will inform end-of-life decision-making, including the specific perspectives of everyone involved, and the need to influence policymakers.
Abstract Background Long-lasting respiratory symptoms have a huge impact on the quality of life in prematurely born children. Aims We aimed to investigate the perinatal and maternal risk factors ...involved in the development of chronic respiratory morbidity in preterm infants, with an emphasis on the importance of Foetal Inflammatory Response Syndrome (FIRS). Study design Prospective cohort study. Subjects Demographic, antenatal, delivery and outcomes data were collected from 262 infants with less than 32 completed weeks of gestational age, over a 10-year period. Outcome measures Presence of chronic lung disease of prematurity and early childhood wheezing. Results In multivariate logistic regression analysis the presence of FIRS appears to be the most important risk factor for both, chronic lung disease of prematurity (OR 31.05, 95% CI 10.7–87.75, p < 0.001) and early childhood wheezing (OR 5.63, 95% CI 2.42–13.05, p = 0.01). In the alternative regression model for early childhood wheezing, with chronic lung disease included as a variable, the statistical significance of FIRS completely vanished (OR 1.15, 95% CI 0.39–3.34, p = 0.79), whilst chronic lung disease became the most important risk factor (OR 23.45, 95% CI 8.5–63.25, p < 0.001). Conclusions Prenatal and early neonatal events are of utmost importance in the development of chronic respiratory symptoms in children. The influence of FIRS on the development of chronic respiratory symptoms goes far beyond its impact on gestational age and may be related to direct inflammation-mediated lung tissue damage. CLD appears to be an intermittent step on the way from FIRS to ECW.
Current evidence suggests that additional pathogenetic factors could play a role in the development of chronic lung disease of prematurity, other than mechanical ventilation and free radical injury. ...The introduction of the concept of "fetal inflammatory response syndrome" offers a new perspective on the pathogenesis of chronic lung disease of prematurity. New statistical approaches could be useful tools in evaluating causal relationships in the development of chronic morbidity in preterm infants. The aim of this study was to test a new statistical framework incorporating path analysis to evaluate causality between exposure to chorioamnionitis and fetal inflammatory response syndrome and the development of chronic lung disease of prematurity. We designed a prospective cohort study that included consecutively born premature infants less than 32 weeks of gestation whose placentas were collected for histological analysis. Histological chorioamnionitis, clinical data, and neonatal outcomes were related to chronic lung disease. Along with standard statistical methods, a path analysis was performed to test the relationship between histological chorioamnionitis, gestational age, mechanical ventilation, and development of chronic lung disease of prematurity. Among the newborns enrolled in the study, 69/189 (36%) had histological chorioamnionitis. Of those with histological chorioamnionitis, 28/69 (37%) were classified as having fetal inflammatory response syndrome, according to the presence of severe chorioamnionitis and funisitis. Histological chorioamnionitis was associated with a lower birth weight, shorter gestation, higher frequency of patent ductus arteriosus, greater use of surfactant, and higher frequency of chronic lung disease of prematurity. Severe chorioamnionitis and funisitis were significantly associated with lower birth weight, lower gestational age, lower Apgar score at 5 minutes, more frequent use of mechanical ventilatory support and surfactant, as well as higher frequency of patent ductus arteriosus and chronic lung disease. The results of the path analysis showed that fetal inflammatory response syndrome has a significant direct (0.66), indirect (0.11), and overall (0.77) effect on chronic lung disease. This study demonstrated a strong positive correlation between exposure of the fetus to a severe inflammatory response and the development of chronic lung disease of prematurity.
To determine the newborn infection rate with group B streptococcus infection (GBS) before and after American Academy of Pediatrics Protocol (AAP) implementation in Croatia, antenatal risk factors, ...neonatal outcome and necessity for introducing national policy for intrapartum chemoprophylaxis. To evaluate the role of intrapartum chemoprophylaxis in preterm labor at < 37 weeks of gestation, premature rupture of membranes at < 37 weeks of gestation, fever during labor, ruptures of membranes > 18 hours before delivery and previous delivery of a sibling with GBS disease. A total of 784 neonates admitted to the Neonatal Intensive Care Unit, from 1 January 2005 to 31 December 2005. 60 (10/1000 live born) developed early-onset infection (EOGBS). The dominant presentation for EOGBS was sepsis (65%), pneumonia (32.2%) and meningitis (3%). Mean gestational age was 34.5 (+/- 5.3) weeks. There were 2 neonatal deaths (3%) in EOGBS, both preterm. EOGBS disease was associated with following risk factors: rupture of the membranes > 12 hours (49.3%), chorioamnionitis (11.9%), status post cerclage (10.4%), diabetes mellitus (4.5%), delivery out of hospital (3%), uroinfection (1.5%). After AAP implementation the incidence of GBS infection decreased from 15/1000 to 10/1000 of live born infants. The mortality from EOGBS dropped from 5% to 3%. The incidence of GBS infection in our study was considerably higher than in all current reports. Reasons for that can be inadequate perinatal screen in some parts of the country and no established policy for intrapartum antibiotic treatment of women with risk factors. Our results documented that intrapartum chemo-prophylaxis for GBS infection significantly reduces perinatal mortality due to neonatal infection and sepsis.
Severity of symptoms in primary dysmenorrhea—a doppler study Dmitrovic, Romana; Peter, Branimir; Cvitkovic-Kuzmic, Andrea ...
European journal of obstetrics & gynecology and reproductive biology,
04/2003, Letnik:
107, Številka:
2
Journal Article
Recenzirano
Objective: Doppler findings in women with severe symptoms of primary dysmenorrhea include high impedance to blood flow in uterine arteries with a preserved cyclic pattern throughout the whole cycle. ...Doppler findings in women who present with mild symptoms of primary dysmenorrhea are not yet documented. The aim of this study was to investigate possible differences in Doppler findings among women with mild and severe primary dysmenorrhea.
Study design: One hundred and fifty four women were examined with color Doppler ultrasound: 50 in the control group, 60 in the mild and 44 in the severe primary dysmenorrhea subgroup. We calculated resistance index in uterine arteries in these women on the first day of the cycle, in the follicular (days 9–12) and the luteal (days 20–23) phase of the cycle and used analysis of variance for comparing results.
Results: The rate of visualization was 100% for uterine and arcuate arteries, 44–76% for the radial and 32–62% for spiral arteries, respectively. A significant difference in Doppler index values among the mild and severe dysmenorrheic group was observed in the luteal phase for the arcuate artery and in all the three measurement periods for the radial and spiral arteries.
Conclusion: There is a difference in Doppler findings between women with mild and severe symptoms of primary dysmenorrhea.
As the other major European countries, Croatia has also seen a marked increase in the rate of caesarean sections. The aim of this study was to determine the most common reasons for caesarean section, ...to compare emergency and elective caesarean section in regard to intraoperative and postoperative complications in both mother and child, and to assess the decision-to-delivery interval (DDI) in our clinic in comparison to current recommendations. Analyzing the results of our research we can say that the new-borns in the group with the elective caesarean section had considerably better Apgar index score in the first minute (p = 0.00056) and in the fifth minute (p = 0.054) than the children born in the group with emergency caesarean section. Children from the group with elective caesarean section had also less frequent asphyxia (p = 0.02315) and considerably less frequent resuscitation (p = 0.0143) than the children from the group with emergency caesarean sections. Only 39.73% of the emergency caesarean sections were performed within the "golden standard" period of 30 minutes. Regarding the data from the literature our results are similar with the ones from developed countries and 30 minute current standard seem to be not achievable.
Perinatal care improves the outcome of triplets Skrablin, Snjezana; Kuvacic, Ivan; Kalafatic, Drzislav ...
European journal of obstetrics & gynecology and reproductive biology,
08/2002, Letnik:
104, Številka:
1
Journal Article
Recenzirano
Objective: To compare pregnancy complications and neonatal outcome of 85 triplet gestations cared for during the 15 years in a single perinatal unit.
Methods: Pregnancies were divided in two groups ...according to the differences in the management plan and their outcomes were compared. Group I (
N=44) consisted of pregnancies cared from 1986 to 1995, using standard model of care: preventive hospitalization from the early second trimester or home bed rest with routine hospitalization after 28–32 weeks of pregnancy, routine clinical and ultrasound examinations, biophysical profile and non-stress tests starting at 28 weeks, expert neonatal care without free access to surfactant or to parenteral nutrition. Group II (
N=41) consisted of pregnancies cared for from 1986 to 2000 using modified care: preventive hospitalization from early second trimester or home bed rest with routine hospitalization after 32 weeks of pregnancy, biophysical profile, non-stress tests and pulsed doppler analysis of fetal umbilical artery, fetal aorta and middle cerebral artery blood flow from as early as 26 weeks, and neonatal care improved by free access to surfactant and parenteral nutrition.
Results: The mean gestational age, mean birth weight, the proportion of growth-retarded infants, the incidence of various maternal complications and immediate neonatal conditions as judged by APGAR scores did not differ between the groups. The incidence of deliveries up to 28 weeks was lower in the group II in comparison to group I, but the proportion of term and near term deliveries was lower. The incidence of cesarean sections was high (91.8%), but significantly increased cesarean delivery rate because of fetal distress was observed in the group II (
P=0.014). Infants in the group II had less frequently uneventful early neonatal period, mainly due to significantly increased conatal infection (
P=0.007) and neonatal encephalopathy rate (
P=0.001). However, perinatal mortality was decreased from 235% in the group I to 142% in the group II for newborns that reached 24 weeks of gestation or more. The decrease of perinatal mortality was observed also in the newborns born after 28 weeks of gestation (123% in the group I and 99% in the group II). None of the children weighing <1000
g died in utero in the group II. Early neonatal death of infants weighing >1500
g was significantly reduced in the group II (
P=0.048).
Conclusion: Advances in neonatal care, but also the delivery of infants in better overall condition must be the explanation for improved outcome of triplet gestations managed by modified care. A higher cesarean section rate because of imminent fetal jeopardy as judged by not only fetal heart rate tracings, but also umbilical, aortic and middle cerebral artery flow analysis, could be the explanation for lowered perinatal mortality and significantly improved outcome in very preterm infants from triplet gestations.
The pernatal outcome of 433 deliveries and 643 newborns, conceived
following IVF-ET procedure at a Dep. of Obst. And Gyn. Of Clinical
Medical Centre Zagreb in the period 2000-2003 is analyzed. The ...results
are compared to the outcome of 20468 other infants born infants in the
same period. The 40,19% of IVF-Et pregnancies were multifetal, among
them 29,06 with twins, 8,96 with triplets and 2,42% with quadruplets.
Among other 20468 deliveries 310 (1,52%) were multifetal, almost
exclusvely twins and only 3 pregnancies with triplets. When correlating
the IVF-ET pregnacies and newborns to all others it was established:
stillbirth 4,41% versus 1,26%; SC 72,46 vs 11,41% ; delivery < 37
weeks 49,85% vs 11,37; infants LBW 40,88% vs 1,42% ; ELBW infants 4,25%
vs 1,03%. In singletons following IVF-ET no difference in relation to
spontaneus concevid, whereas well-defined differences in mutiple
pregnacies between IVF-ET and spontaneus concevide twins were found: FM
in IVF-ET was 66,7 ‰ vs 14,5 ‰, ENM 25,0‰ vs
30,0‰; PM 92,0‰ vs 53,0 ‰. In 111 triplets following
IVF-ET fetal mortality was 72,0‰, ENM 36,0 ‰, and PM
108,0‰. Gross malformations in the total IVF-ET group were 3,77%
vs 1,67% in othere pregnacies. The authors have confirmed the higher
risk of IVF-ET pregnacies, that is caused by higher rate of mutiple
pregnacies, of newborns < 37 w., infants < 2500 g. The pregnacies
following IVF-ET are high risk pregnancies, they claim for special
attention and perinatal care.
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