Miriam Gatt

Syndromes and malformations associated with congenital heart disease in a population-based study

Congenital cardiac malformations are frequently associated with non-cardiac malformations and chromosomal anomalies. Management is therefore influenced by interventional needs for all of the various anomalies. We have studied the association of congenital heart disease with extracardiac anomalies in the relatively closed population of Malta, where echocardiographic screening of all syndromic/multiply malformed infants is routinely carried out. Malformations were classified by using the EUROCAT method, for the first time. During 1990-1994, the birth prevalence of congenital heart disease was 8.8/1000 live births (n = 231). Of these, 21 (9%) had recognised chromosomal anomalies (0.80/1000 live births; 95% CI: 0.51-1.25), four (2%) had recognised non-chromosomal syndromes and 14 (6%) had other, major, non-cardiac malformations (0.69/1000 live births; 95% CI: 0.42-1.11). The commonest non-cardiac anomalies were musculoskeletal anomalies. Down syndrome accounted for 95% of all syndromic congenital heart disease, with a birth prevalence of 0.73/1000 live births (95% CI: 0.45-1.16). Comparison of these results with earlier studies showed wide disparities between studies, and this was attributed to differences in methods. such as differing inclusion criteria for both congenital heart disease and syndromes and malformations. The commonest lesion found in association with Down syndrome was isolated ventricular septal defect, not atrioventricular septal defect, and this was attributed to our screening process which identifies small lesions which would otherwise have been clinically missed and/or closed spontaneously.

Obstetric outcomes in immigrants of African nationality

African women delivering in the Maltese Islands are either regular or irregular migrants. The latter group presents significant socio-economic problems. Objective: This study sets out to compare the obstetric outcomes of African-nationals delivering in Malta to the general population. Study design: The obstetric data of three subgroups of women - those from the Maghreb region; the sub-Saharan and Horn of Africa; and the overall population registered for the Maltese Islands were obtained using the computerised National Obstetrics Information System. Results: Women from the sub-Saharan regions were statistically younger than those from the Maghreb region or the general population. African women from both regions were more likely to be multiparous; and were more likely to have experienced a previous perinatal loss. The multiple pregnancy rates were significantly higher in both African groups. Women from the sub-Saharan region were more likely to suffer from sexual and blood-borne infections. African women had lower obstetric intervention rates but higher operative deliveries. Infants born to African women were more likely to be premature and of low birth weight. Conclusion: Women originating from the African continent particularly from the sub-Saharan regions present socio- biological and cultural differences which can contribute towards adverse obstetric and perinatal outcomes.

Contribution of Congenital Anomalies to Neonatal Mortality Rates in Malta.

BACKGROUND Neonatal mortality is a public health concern, and congenital anomalies contribute significantly to this mortality. This paper describes trends in neonatal mortality in Malta separately for congenital anomaly and non-congenital anomaly causes. METHODS Data for neonatal deaths of 22-week gestation onwards registered between 1994-2013 were obtained from the National Mortality Register. Chi-square tests were used to analyse 5-year time trends and differences in proportions of causes of neonatal deaths. Neonatal mortality was compared with other European countries. RESULTS Between 1994 and 2013, 441 neonatal deaths and 84 821 livebirths were registered, giving a neonatal mortality of 5.2 per 1000 livebirths. Congenital anomalies accounted for 36.7% (n = 162) of the neonatal deaths, while the remaining 63.3% (n = 279) were attributed to non-congenital causes. During the 20-year period, neonatal mortality due to non-congenital causes decreased from 4.6 per 1000 livebirths in 1994-98 to 2.5 per 1000 in 2009-13, while that due to congenital anomalies remained stable (2.0 per 1000 livebirths in 1994-98 and 2.2 per 1000 in 2009-13). This has resulted in comparatively higher proportions of neonatal deaths attributed to congenital anomalies in recent years (45.9% in 2009-13 vs. 29.9% in 1994-98). Comparing neonatal mortality reported from European countries, Malta has a high rate most marked for deaths due to congenital anomalies. CONCLUSIONS During 1994-2013, neonatal mortality has decreased due to a decline of non-congenital causes of death, possibly related to improved health care. The proportionate neonatal mortality attributed to congenital anomalies has increased and is the highest reported from Europe. This may be explained by the fact that termination of pregnancy is illegal in Malta.

Factors influencing the future of paediatric private practice in Malta

In Malta, the health system is hybrid, with similarities to both UK system and the US system, where the National Health Service is supplemented by private practice. This is widely performed either as a primary job or as a supplement to a government salary. This article reviews unfavourable secular trends in Maltese fertility, births, marriages, separations, single parenthood and loans incurred after marriage, and relates them to (equally unfavourable in terms of private practice) escalating numbers of paediatricians working in private practice. Overall, future prospects appear bleak for private practice in this branch of medicine, with a dwindling patient pool being shared by an ever-increasing number of paediatricians. The only identifiable factor that may mitigate is the potential for more private health insurance uptake. This must be coupled with a movement to improve the perception of a substantial proportion of the public that facilities are poorer in the private health sector than in the NHS service. Since Malta is a developed, EU country, these results may (cautiously) be extrapolated to other, larger developed countries.

Risk factors for prematurity in the Maltese Islands: 1999–2006

Prematurity remains one of the main causes of neonatal mortality and morbidity even in countries that have welldeveloped comprehensive maternity and neonatal services. Objective: A review of the epidemiology and the short-term complications arising from natural or iatrogenic prematurity in modern practice is necessary to assess the true import of this obstetric complication. Methodology: All deliveries with known gestational age at delivery in the Maltese Islands during the period 1999–2006 were included in the study (23,073 maternities with a total of 23,422 births). These maternities included a total of 1279 delivered at a documented 36 or less completed weeks of gestation. Results: During the period under review the prematurity rate amounted to 6.2% of all maternities. Iatrogrenic-induced births accounted for 33.9% of the total. A premature birth was statistically more likely to occur in women at their extremes of reproductive life ( 17 years: OR = 1.16; or 30 years: OR = 1.44: p < 0.0001), or who gave a history of multiparity (Para 3+: OR = 1.56: p = 0.008) or previous recurrent miscarriage (OR = 1.79: p = 0.008) or fetal loss (OR = 3.17: p < 0.0001). The current pregnancy was statistically more likely to be a multiple pregnancy (OR = 13.52: p < 0.0001) or be complicated by hypertension (OR = 2.62: p < 0.0001), pre-existing (OR = 7.50: p < 0.0001) or gestational (OR = 2.4: p < 0.0001) diabetes, or antenatal bleeding (OR = 9.22: p < 0.0001). Premature births were statistically more likely to deliver by Caesarean section (OR = 2.13: p < 0.0001). The stillbirth and neonatal mortality is significantly higher (OR = 73.0: p < 0.0001) in premature births; while the premature infant is very much more likely to require resuscitation and life support interventions (low 5 min Apgar score: OR = 36.5: p < 0.0001). The neonatal period of the premature infant is fraught with risks of significant serious complications such as respiratory distress syndrome (OR = 9.14: p < 0.0001), hyperbilirubinaemia (OR = 16.0: p < 0.0001) and sepsis (OR = 16.0: p < 0.0001). Conclusions: The short-term morto-morbidity and the long-term morbidity associated with preterm births necessitates a determined drive to identify those pregnant women at risk so that proactive intervention management can be instituted.