Sajjad ur Rahman

Socioeconomic associations of improved maternal, neonatal, and perinatal survival in Qatar

This retrospective study analyzed the temporal association between socioeconomic development indices and improved maternal, neonatal, and perinatal survival in the State of Qatar over a period of 35 years (1974–2008). We explored the association between reduction in poverty, improvement in maternal education, and perinatal health care on the one hand, and increased maternal, neonatal, and perinatal survival on the other hand. Yearly mortality data was ascertained from the perinatal and neonatal mortality registers of the Women’s Hospital and the national database in the Department of Preventive Medicine at Hamad Medical Corporation in Doha. A total of 323,014 births were recorded during the study period. During these 35 years, there was a remarkable decline (P < 0.001) in Qatar’s neonatal mortality rate from 26.27/1000 in 1974 to 4.4/1000 in 2008 and in the perinatal mortality rate from 44.4/1000 in 1974 to 10.58/1000 in 2008. Qatar’s maternal mortality rate remained zero during 1993, 1995, and then in 1998–2000. The maternal mortality rate was 11.6/100,000 in 2008. For the rest of the years it has been approximately 10/100,000. Across the study period, the reduction in poverty, increase in maternal education, and improved perinatal health care were temporally associated with a significant improvement in maternal, neonatal, and perinatal survival. The total annual births increased five-fold during the study period, with no negative impact on survival rates. Neonatal mortality rates in Qatar have reached a plateau since 2005. We also conducted a substudy to assess the association between improvements in survival rates in relation to health care investment. For this purpose, we divided the study period into two eras, ie, era A (1974–1993) during which major health care investment was in community-based, low-cost interventions, and era B (1994–2008) during which the major health care investment was in high-technology institutional interventions. Although from 1974–1993 (era A) the per capita health expenditure increased by only 19% as compared with a 137% increase in 1994–2008 (era B). The decline in neonatal and perinatal mortality rates was three times steeper during era A than in era B. The decline in neonatal and perinatal mortality rates was also significant (P < 0.001) when analyzed separately for era A and era B. We concluded that across the 35-year period covered by our study, the reduction in poverty, increased maternal education, and improved perinatal health care were temporally associated with improved maternal, neonatal, and perinatal survival in the State of Qatar. From the subanalysis of era A and era B, we concluded that low-cost, community-based interventions, on the background of socioeconomic development, have a stronger impact on maternal, neonatal, and perinatal survival as compared with high-cost institutional interventions.

Hereditary multiple intestinal atresia (HMIA) with severe combined immunodeficiency (SCID): a case report of two siblings and review of the literature on MIA, HMIA and HMIA with immunodeficiency over the last 50 years

Hereditary multiple intestinal atresia (HMIA), a presumed autosomal recessive disorder, is an unusual and rare form of recurrent intestinal atresia which can be associated with severe combined immunodeficiency (SCID). The combination of HMIA and SCID is invariably lethal. The authors describe this fatal association in two siblings. The parents are consanguineous and have three other normal healthy children. Both index cases had abnormal antenatal ultrasounds and were symptomatic after birth. The final diagnosis of HMIA with SCID was confirmed in both siblings. They were never able to receive enteral feeds, remained totally dependent on parenteral nutrition, had repeated episodes of sepsis and died after a very difficult neonatal intensive care course. In this article we have reviewed the clinical course and outcome of both cases. The existing literature on multiple intestinal atresia, HMIA and HMIA with immunodeficiency is also reviewed.

Neuroprotection for Perinatal Hypoxic Ischemic Encephalopathy in Low- and Middle-Income Countries.

From the Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada; 2 3 the standard of care for treating newborns with moderate to severe HIE. Therapeutic hypothermia has been found to reduce the risk of death or major neurodevelopmental disability at age 18 months (risk ratio [RR], 0.76; 95% CI, 0.69-0.84) and to increase survival with normal neurologic function (RR, 1.63; 95% CI, 1.36-1.95). Recent studies have confirmed improved neurocognitive outcomes at school age. Those studies involved predominantly developed countries. In contrast, a systematic review of 7 trials including 567 newborns from LMI countries, using mainly low-cost cooling techniques, did not show a significant reduction in neonatal mortality (RR, 0.74; 95% CI, 0.441.25). Although the point estimate is consistent with estimates from the developed world, the wide CI of that result means that a clinically important benefit or harm could not be excluded. Furthermore, there was insufficient long-term follow-up to allow assessment of whether hypothermia had improved neurodevelopmental outcomes. The heterogeneity of outcomes in studies from LMI countries may be an artifact of poorly designed studies, many of which were very small. The largest study in that review, which carried almost one-half of the weight in the primary outcome (neonatal mortality), may have introduced selection bias by including more boys (85%) and violated its protocol by including 20% cases with mild encephalopathy. Overall, 15% of the patients in these studies hadmild encephalopathy, and, consistent with this, only 12% required ventilation. Newborns with mild HIE have a low risk of mortality, reducing the study’s power and potentially leading to a false conclusion that the intervention is not conclusive when the intervention was not applied to the correct target population. It is unclear whether the low frequency of mechanical ventilation reflects only selection for milder cases, or whether resource limitations constrained care. Alternatively, the heterogeneity of outcomes potentially could be “real,” that is, related to medical factors that impair

Outcomes of 28+1 to 32+0 Weeks Gestation Babies in the State of Qatar: Finding Facility-Based Cost Effective Options for Improving the Survival of Preterm Neonates in Low Income Countries

In this retrospective study we did a comparative analysis of the outcome of 28+1 to 32+0 weeks gestation babies between the State of Qatar and some high income countries with an objective of providing an evidence base for improving the survival of preterm neonates in low income countries. Data covering a five year period (2002–2006) was ascertained on a pre-designed Performa. A comparative analysis with the most recent data from VON, NICHD, UK, France and Europe was undertaken. Qatar’s 28+1 to 32+0 weeks Prematurity Rate (9.23 per 1,000 births) was less than the UK’s (p < 0.0001). Of the 597 babies born at 28+1 to 32+0 weeks of gestation, 37.5% did not require any respiratory support, while 31.1% required only CPAP therapy. 80.12% of the MV and 96.28% of CPAP therapy was required for <96 hours. 86.1% of the mothers had received antenatal steroids. The 28+1 to 32+0 weeks mortality rate was 65.3/1,000 births with 30.77% deaths attributable to a range of lethal congenital and chromosomal anomalies. The survival rate increased with increasing gestational age (p < 0.001) and was comparable to some high income countries. The incidence of in hospital pre discharge morbidities in Qatar (CLD 2.68%, IVH Grade III 0.84%, IVH Grade IV 0.5%, Cystic PVL 0.5%) was less as compared to some high income countries except ROP ≥ Stage 3 (5.69%), which was higher in Qatar. The incidence of symptomatic PDA, NEC and severe ROP decreased with increasing gestational age (p < 0.05). We conclude that the mortality and in hospital pre discharge morbidity outcome of 28+1 to 32+0 weeks babies in Qatar are comparable with some high income countries. In two thirds of this group of preterm babies, the immediate postnatal respiratory distress can be effectively managed by using two facility based cost effective interventions; antenatal steroids and postnatal CPAP. This finding is very supportive to the efforts of international perinatal health care planners in designing facility-based cost effective options for low income countries.

Neonatal Mortality: Incidence, Correlates and Improvement Strategies

The neonatal period (birth to 28th day of life) is the most vulnerable and high-risk time in lifebecause of the highest mortality and morbidity incidence in human life during this period. An estimated 40percent of deaths in children less than five years of age occur during the first 28 days of life (WHO, 2011a). The remaining 60 percent of deaths occur during the subsequent 1800 days of the first five years of life. The average daily mortality rate during the neonatal period is close to 30 fold higher than during the postnatal period (one month to one year of age). During 2010, an estimated 7.7 million children under five years of age died worldwide (Rajaratnam et al., 2010). This included 3.1 million neonatal deaths, 2.3 million post neonatal deaths (age one month to one year) and 2.3 million childhood deaths (age 1-4 years).

The national perinatal mortality rate in the State of Qatar during 2011; trends since 1990 and comparative analysis with selected high-income countries: The PEARL Study Project*

Abstract Objective: To prospectively ascertain Qatar’s national perinatal mortality rate (PMR) during 2011, compare it with recent data from selected high-income countries, and analyze trends in Qatar’s PMR between 1990 and 2011 using historical data. Study design: A national prospective cohort study. Methods: National data on live births, stillbirths, and early neonatal mortality (day 0–6) were collected from all public and private maternity units in Qatar (1st January–December 31st 2011) and compared with historical perinatal mortality data (1990–2010) ascertained from the database of maternity and neonatal units of Women’s Hospital and annual reports of Hamad Medical Corporation (HMC). For inter-country comparison, country data were extracted from the World Health Statistics published by WHO in 2011 and from the European Perinatal Health Report published by the Europeristat project in 2008. Results: A total of 20,725 births (20,583 live births plus 142 stillbirths) were recorded during the study period. Qatar’s national PMR during 2011 was 9.55 [early neonatal mortality rate (ENMR) 2.7 and stillbirth rate (SBR) 6.85], which was a significant improvement from a PMR of 13.2 in 1990 [risk ratio (RR) 0.72, 95% confidence interval 0.58–0.89, P=0.002]. This improvement in PMR was more significant in ENMR (P<0.001) than in SBR (P=0.019). The stillbirths constituted 55% of PMR in 1990, which increased to 71.72% of PMR during 2011. The RR of PMR had a significant downwards trend between 1990 and 2011 (P=0.016). Qatar’s 2011 PMR, SBR, and ENMR are comparable to those of selected high-income counties. Conclusions: Qatar’s PMR, ENMR, and SBR have significantly improved between 1990 and 2011, and are currently comparable to those of selected high-income countries. An in-depth research to assess the correlates and determinants of stillbirth and perinatal mortality in Qatar is indicated.

Use of octeriotide in the management of neonatal chylothorax secondary to repair of congenital diaphragmatic hernia: a report of two cases and review of literature.

Chylothorax, a known complication of surgery for Congenital Diaphragmatic hernia, can sometimes be resistant to treat. Octeriotide (Somatostatin analogue) can be useful in this situation. However, the dose and schedule of Octeriotide therapy in neonates is not well established. We report two cases of resistant chylothorax following surgery for congenital diaphragmatic hernia which were successfully managed by using an escalating infusion of octeriotide. The literature on the subject is also reviewed.

Respiratory distress syndrome due to a novel homozygous ABCA3 mutation in a term neonate.

The authors report, for the first time in the literature, a case of respiratory distress syndrome in a term baby due to homozygosity for a p.Trp308Arg/W308R substitution in the ATP-binding cassette transporter 3. The sequence was confirmed by genetic analysis of the baby and both parents. Management and long-term outcome of a patient carrying this novel genetic defect have not been reported in the literature before. Currently, lung transplant appears to be the only long-term survival option available, for which, our patient is being evaluated.

The incidence of low birth weight and intrauterine growth restriction in relationship to maternal ethnicity and gestational age at birth – A PEARL study analysis from the State of Qatar

Objective: To analyze the association between maternal ethnicity and gestational age with the incidence of low birth weight and intrauterine growth restriction. Study Design: Prospective, analytic study Methods: The study was conducted between March 14th and April 4th 2011 in Womens Hospital HMC. The data was ascertained from the delivery register of labor ward on daily basis using predesigned, structured questionnaire. Data was stratified according to the maternal ethnicity groups and gestational age at birth (term and preterm). Results: The total deliveries during the study period were 890; 35.5% Qatari (n 316) and 64.5% non-Qatari (n 574). The incidence of LBW was 12.36% (n 110). The difference of LBW incidence between Qatari (13.6% n 43) and non-Qatari (11.67% n 67) groups was non significant (RR 1.17, 95% CI 0.82-1.67, p = 0.401). The same was between non-Qatari sub groups (p < 0.05). The incidence of IUGR was 6% (n 54; 49.09% of LBW). The incidence of IUGR between Qatari (5.7% n 18) and non-Qatari (6.27% n 36) groups was significant (RR 0.45, 95% CI 0.3-0.6 p>0.05). The incidence of LBW was 7.85% (n 60) in term babies and 39.68% (n 50) in preterm babies. The incidence if IUGR was 3.79% (n 29) in term babies and 19.84% (n 25) in preterm babies. Preterm babies had a five times higher risk of both being LBW (RR 5.05; 95%CI 3.65-6.99; p < 0.001) and IUGR (RR 5.23; 95% CI 3.17-8.62; p < 0.001). Conclusion: The incidence of low birth weight is independent of maternal ethnicity in Qatar. However, the incidence of IUGR is significantly higher among the non-Qatari population. The relative risk of being LBW or IUGR is five times higher in preterm babies. Further in depth studies are indicated.

Scimitar syndrome with absent right pulmonary artery and severe pulmonary hypertension treated with coil occlusion of aortopulmonary collaterals in a term neonate

Scimitar syndrome (SS) is a rare congenital malformation with an estimated incidence of approximately 2 in 100 000 births. A wide clinical spectrum is observed in children with this syndrome. The common clinical presentation in infancy is respiratory distress and tachypnoea due to associated pulmonary hypoplasia, pulmonary overcirculation and/or pulmonary hypertension. Babies with SS presenting with cardiac failure are prone to develop exaggerated pulmonary vascular disease. Hence early intervention, using either coil embolisation or surgical intervention, is indicated. We are reporting a case of a term baby boy who presented with respiratory failure during the first 24 h of life. Echocardiogram and CT angiogram revealed SS. The baby needed intubation due to respiratory failure. Aortopulmonary collaterals, identified on aortic angiogram, were successfully occluded with detachable coils.