Guid Oei

Predictive value of cervical length measurement and fibronectin testing in threatened preterm labor

OBJECTIVE: To estimate the performance of combining cervical length measurement with fetal fibronectin testing in predicting delivery in women with symptoms of preterm labor. METHODS: We conducted a prospective nationwide cohort study in all 10 perinatal centers in The Netherlands. Women with symptoms of preterm labor between 24 and 34 weeks of gestation with intact membranes were included. In all women, qualitative fibronectin testing (0.050-microgram/mL cutoff) and cervical length measurement were performed. Logistic regression was used to predict spontaneous preterm delivery within 7 days after testing. A risk less than 5%, corresponding to the risk for women with a cervical length of at least 25 mm, was considered as low risk. RESULTS: Between December 2009 and August 2012, 714 women were enrolled. Fibronectin results and cervical length were available for 665 women, of whom 80 (12%) delivered within 7 days. Women with a cervical length of at least 30 mm or with a cervical length between 15 and 30 mm with a negative fibronectin result were at low risk (less than 5%) of spontaneous delivery within 7 days. Fibronectin testing in case of a cervical length between 15 and 30 mm additionally classified 103 women (15% of the cohort) as low risk and 36 women (5% of the cohort) as high risk. CONCLUSION: Cervical length measurement, combined with fetal fibronectin testing in case of a cervical length between 15 and 30 mm, improves identification of women with a low risk to deliver spontaneously within 7 days. LEVEL OF EVIDENCE: II

Implementation of simulation in surgical practice: Minimally invasive surgery has taken the lead: The Dutch experience

Minimal invasive techniques are rapidly becoming standard surgical techniques for many surgical procedures. To develop the skills necessary to apply these techniques, box trainers and/or inanimate models may be used, but these trainers lack the possibility of inherent objective classification of results. In the past decade, virtual reality (VR) trainers were introduced for training minimal invasive techniques. Minimally invasive surgery (MIS) is, by nature, very suitable for this type of training. The specific psychomotor skills and eye–hand coordination needed for MIS can be mastered largely using VR simulation techniques. It is also possible to transfer skills learned on a simulator to real operations, resulting in error reduction and shortening of procedural operating time. The authors aim to enlighten the process of gaining acceptance in the Netherlands for novel training techniques. The Dutch Societies of Surgery, Obstetrics and Gynecology, and Urology each developed individual training curricula for MIS using simulation techniques, to be implemented in daily practice. The ultimate goal is to improve patient safety. The authors outline the opinions of actors involved, such as different simulators, surgical trainees, surgeons, surgical societies, hospital boards, government, and the public. The actual implementation of nationwide training curricula for MIS is, however, a challenging step.

Cost-effectiveness of cardiotocography plus ST analysis of the fetal electrocardiogram compared with cardiotocography only

Objective. To assess the cost‐effectiveness of addition of ST analysis of the fetal electrocardiogram (ECG; STAN®) to cardiotocography (CTG) for fetal surveillance during labor compared with CTG only. Design. Cost‐effectiveness analysis based on a randomized clinical trial on ST analysis of the fetal ECG. Setting. Obstetric departments of three academic and six general hospitals in The Netherlands. Population. Laboring women with a singleton high‐risk pregnancy, a fetus in cephalic presentation, a gestational age >36weeks and an indication for internal electronic fetal monitoring. Methods. A trial‐based cost‐effectiveness analysis was performed from a health‐care provider perspective. Main Outcome Measures. Primary health outcome was the incidence of metabolic acidosis measured in the umbilical artery. Direct medical costs were estimated from start of labor to childbirth. Cost‐effectiveness was expressed as costs to prevent one case of metabolic acidosis. Results. The incidence of metabolic acidosis was 0.7% in the ST‐analysis group and 1.0% in the CTG‐only group (relative risk 0.70; 95% confidence interval 0.38–1.28). Per delivery, the mean costs per patient of CTG plus ST analysis (n= 2 827) were €1 345 vs. €1 316 for CTG only (n= 2 840), with a mean difference of €29 (95% confidence interval −€9 to €77) until childbirth. The incremental costs of ST analysis to prevent one case of metabolic acidosis were €9 667. Conclusions. The additional costs of monitoring by ST analysis of the fetal ECG are very limited when compared with monitoring by CTG only and very low compared with the total costs of delivery.

Quantitative fetal fibronectin testing in combination with cervical length measurement in the prediction of spontaneous preterm delivery in symptomatic women.

To evaluate whether in symptomatic women, the combination of quantitative fetal fibronectin (fFN) testing and cervical length (CL) improves the prediction of preterm delivery (PTD) within 7 days compared with qualitative fFN and CL.

Suboptimal bonding impairs hormonal, epigenetic and neuronal development in preterm infants, but these impairments can be reversed

This review aimed to raise awareness of the consequences of suboptimal bonding caused by prematurity. In addition to hypoxia–ischaemia, infection and malnutrition, suboptimal bonding is one of the many unnatural stimuli that preterm infants are exposed to, compromising their physiological development. However, the physiological consequences of suboptimal bonding are less frequently addressed in the literature than those of other threatening unnatural stimuli.

Features of Heart Rate Variability Capture Regulatory Changes During Kangaroo Care in Preterm Infants

Objective To determine whether heart rate variability (HRV) can serve as a surrogate measure to track regulatory changes during kangaroo care, a period of parental coregulation distinct from regulation within the incubator. Study design Nurses annotated the starting and ending times of kangaroo care for 3 months. The pre‐kangaroo care, during‐kangaroo care, and post‐kangaroo care data were retrieved in infants with at least 10 accurately annotated kangaroo care sessions. Eight HRV features (5 in the time domain and 3 in the frequency domain) were used to visually and statistically compare the pre‐kangaroo care and during‐kangaroo care periods. Two of these features, capturing the percentage of heart rate decelerations and the extent of heart rate decelerations, were newly developed for preterm infants. Results A total of 191 kangaroo care sessions were investigated in 11 preterm infants. Despite clinically irrelevant changes in vital signs, 6 of the 8 HRV features (SD of normal‐to‐normal intervals, root mean square of the SD, percentage of consecutive normal‐to‐normal intervals that differ by >50 ms, SD of heart rate decelerations, high‐frequency power, and low‐frequency/high‐frequency ratio) showed a visible and statistically significant difference (P < .01) between stable periods of kangaroo care and pre‐kangaroo care. HRV was reduced during kangaroo care owing to a decrease in the extent of transient heart rate decelerations. Conclusion HRV‐based features may be clinically useful for capturing the dynamic changes in autonomic regulation in response to kangaroo care and other changes in environment and state.

Comparison of the Actim Partus test and the fetal fibronectin test in the prediction of spontaneous preterm birth in symptomatic women undergoing cervical length measurement

OBJECTIVE To compare the accuracy of the Actim Partus test and fetal fibronectin (fFN) test in the prediction of spontaneous preterm delivery within seven days in symptomatic women undergoing cervical length measurement. STUDY DESIGN We performed a post-hoc analysis on frozen samples of a nationwide cohort study in all 10 perinatal centres in the Netherlands. We selected samples from women with signs of preterm labour between 24 and 34 weeks of gestational age and a cervical length below 30mm. Delivery within seven days after initial assessment was the primary endpoint. We calculated sensitivity, specificity, and positive and negative predictive values for the combination of both the Actim Partus test and fFN test with cervical length. A test was considered positive in case of a cervical length between 15 and 30mm with a positive Actim Partus or fFN test, and a cervical length below 15mm regardless the test result. RESULTS In total, samples of 350 women were tested, of whom 69 (20%) delivered within seven days. Eighty-four women had a positive Actim Partus test and 162 women a positive fFN test, of whom 54 (64%) and 63 (39%) delivered within seven days, respectively. Ninety-seven women had a cervical length below 15mm, of whom 50 (52%) delivered within seven days. Sensitivity, specificity, positive and negative predictive values of combining cervical length with the Actim Partus test or the fFN test were 91%, 75%, 47% and 97%, and 96%, 58%, 36% and 98%, respectively. CONCLUSION According to this post-hoc study, in combination with cervical length, the Actim Partus test could be used as an alternative for the fFN test to identify women who will not deliver within seven days after presentation. Further evidence should be collected in a prospective comparative study.

Unlike Kangaroo care, mechanically simulated Kangaroo care does not change heart rate variability in preterm neonates

BACKGROUND While numerous positive effects of Kangaroo care (KC) have been reported, the duration that parents can spend kangarooing is often limited. AIM To investigate whether a mattress that aims to mimic breathing motion and the sounds of heartbeats (BabyBe GMBH, Stuttgart, Germany) can simulate aspects of KC in preterm infants as measured by features of heart rate variability (HRV). METHODS A within-subject study design was employed in which every routine KC session was followed by a BabyBe (BB) session, with a washout period of at least 2 h in between. Nurses annotated the start and end times of KC and BB sessions. Data from the pre-KC, KC, post-KC, pre-BB, BB and post-BB were retrieved from the patient monitor via a data warehouse. Five time-domain features of HRV were used to compare both types of intervention. Two of these features, the percentage of decelerations (pDec) and the standard deviation of decelerations (SDDec), were developed in a previous study to capture the contribution of transient heart rate decelerations to HRV, a measure of regulatory instability. RESULTS A total of 182 KC and 180 BabyBe sessions were analyzed in 20 preterm infants. Overall, HRV decreased during KC and after KC. Two of the five features showed a decrease during KC, and all features decreased in the post-KC period (p ≤ 0.01). The BB mattress as employed in this study did not affect HRV. CONCLUSION Unlike KC, a mattress that attempts to mimic breathing motion and heartbeat sounds does not affect HRV of preterm infants.

Board 334 - Research Abstract The Effect of Obstetric Team Training on Perinatal and Maternal Outcome: A Large Multicenter Randomized Controlled Tria (Submission #1092)

Introduction/Background Inquiries have shown that leading causes of substandard care are poor communication and dysfunctional medical teams. In an earlier study we have shown that a one day obstetric team training course improves behavior of professionals six months after the training during unannounced simulated obstetric emergency situations (level 3 Kirkpatrick).1 The question which remains is whether training of healthcare professionals really does improve patient outcome? (level 4 Kirkpatrick). The research question of this study is: Does a one day training of multi-professional obstetric teams in crew resource management (CRM) and medicals skills in a simulation center reduce perinatal and maternal morbidity.2 Methods The obstetric departments of 24 Dutch hospitals were randomly allocated to a one day, multi-professional team training in a medical simulation center or to no such training. The training was mandatory for all employed staff, including gynecologists, residents, midwives and nurses. Team training was given with high-ﬠdelity manikins and facilitated by a communication expert and an obstetrician. Scenarios were not repeated. Eighty percent of time was spent to CRM training and 20% to training of medical skills. For comparison of patient outcome between training and non-training group, data about five maternal and perinatal complications were prospectively collected (primary outcome: perinatal asphyxia, trauma due to shoulder dystocia, eclampsia, severe postpartum hemorrhage and hypoxic-ischemic encephalopathy (HIE)). Data collection was verified with the Dutch Perinatal Registry. For a baseline measurement of these complications, a retrospective search in all hospitals was done. Secondary outcome measures consist of: maternal and perinatal mortality. A Chi-squared test for statistical analysis was used. Results Obstetric departments from 12 hospitals underwent teamwork training. In total 74 gynecologists, 36 residents, 79 midwives and 282 nurses were trained. Overall evaluation by the trainees of the training was 8.7 (scale 0 to 10). During the follow-up period 30,705 children were born in the participating hospitals, 15,991 in the intervention and 14,714 in the control group. The primary outcome measure (consisting of the combination of five maternal and perinatal outcomes) was not significantly different between the intervention and the control group (RR 0.89 (95% CI 0.77-1.02); p 0.093). However, the analysis of the separate maternal and perinatal outcomes showed a significant lower number of trauma due to shoulder dystocia in the intervention group compared to the control group (RR 0.60 (95% CI 0.36-0.997); p 0.046). This same significant effect was seen in the intervention group before and after training (RR 0.53 (95% CI 0.33-0.87); p 0.011). Although there was no significant difference in perinatal mortality between the intervention and control group, there was a trend towards lower perinatal mortalitity in the intervention group versus the control group (RR 0.78 (95% CI 0.57-1.07); p 0.12). The same trend was found before and after training in the intervention group (RR 0.78 (95% CI 0.58-1.06); p 0.118). There was a significant difference in neonatal mortality between the intervention and control group (RR 0.48 (95% CI 0.23-0.999); p 0.045), however this difference was not found over time (RR 1.4 (95% CI 0.54-3.4); p 0.493). Conclusion The obstetric team training did not improve the combined maternal and perinatal outcome. There was no effect on maternal outcome, however there was an effect on perinatal outcome. Trauma due to shoulder dystocia and neonatal mortality decreased significantly (reduction 40 to 50%) in the hospitals that received the simulation training with a not significant trend towards lower perinatal mortality (reduction 22%). However, the decrease in neonatal mortality was not seen over time. This one day obstetric simulation-based team training seems to have a positive translational effect on perinatal outcome but not on maternal outcome. The limited effect might be due to lack of repetition (Ericcson).3,4 References 1. Fransen AF, Van de Ven J, Merién AE, de Wit-Zuurendonk LD, Houterman S, Mol BW, Oei SG. Effect of obstetric team training on team performance and medical technical skills: a randomised controlled trial. BJOG 2012;119:1387–93. 2. van de Ven J, Houterman S, Steinweg RA, Scherpbier AJ, Wijers W, Mol BW, Oei SG; TOSTI-Trial Group. Reducing errors in health care: cost-effectiveness of multidisciplinary team training in obstetric emergencies (TOSTI study); a randomised controlled trial. BMC Pregnancy Childbirth. 2010:8;10:59. 3. Ericsson KA, Krampe RT, Tesch-Römer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100:363–406. 4. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based medical education with deliberate practice yield better Results than traditional clinical education? A meta-analytic comparative review of the evidence. Academic Medicine 2011;86:706–11. Disclosures None.

Multidisciplinary consensus on screening for, diagnosis and management of fetal growth restriction in the Netherlands

BackgroundScreening for, diagnosis and management of intrauterine growth restriction (IUGR) is often performed in multidisciplinary collaboration. However, variation in screening methods, diagnosis and management of IUGR may lead to confusion. In the Netherlands two monodisciplinary guidelines on IUGR do not fully align. To facilitate effective collaboration between different professionals in perinatal care, we undertook a Delphi study with uniform recommendations as our primary result, focusing on issues that are not aligned or for which specifications are lacking in the current guidelines.MethodsWe conducted a Delphi study in three rounds. A purposively sampled selection of 56 panellists participated: 27 representing midwife-led care and 29 obstetrician-led care. Consensus was defined as agreement between the professional groups on the same answer and among at least 70% of the panellists within groups.ResultsPer round 51 or 52 (91% - 93%) panellists responded. This has led to consensus on 27 issues, leading to four consensus based recommendations on screening for IUGR in midwife-led care and eight consensus based recommendations on diagnosis and eight on management in obstetrician-led care. The multidisciplinary project group decided on four additional recommendations as no consensus was reached by the panel. No recommendations could be made about induction of labour versus expectant monitoring, nor about the choice for a primary caesarean section.ConclusionsWe reached consensus on recommendations for care for IUGR within a multidisciplinary panel. These will be implemented in a study on the effectiveness and cost-effectiveness of routine third trimester ultrasound for monitoring fetal growth. Research is needed to evaluate the effects of implementation of these recommendations on perinatal outcomes.Trial registrationNTR4367.