Objective: To evaluate the clinical application of simultaneous recordings of pulsed wave Doppler (PWD) signals in pulmonary artery and vein as alternative sampling site for assessment of arrhythmias in the fetus. Design: Prospective, cross-sectional study. Setting: Tertiary referral centre for fetal cardiology. Patients and methods: From July 1999 to July 2005 PWD was used in pulmonary vessels to assess fetal arrhythmias at 15-40 weeks' gestation. Sample volume placement in the peripheral lung vessels was guided by colour flow mapping on a four-chamber section of the fetal heart. Atrial and ventricular systoles were identified from the pulmonary venous and arterial signals respectively. M-mode recordings were used for comparison. Outcome measures: Diagnosis of fetal arrhythmias. Results: Of 129 cases, 15 had supraventricular tachycardia, 12 with 1:1 atrioventricular conduction and 3 with atrial flutter and 2:1 block. There were 96 cases of atrial and 7 of ventricular premature beats, 2 of sinus bradycardia, 8 of variable degree heart block and 1 of ventricular tachycardia. PWD was diagnostic in 119 cases. PWD was better than M mode for diagnosis of premature beats and added information about mechanisms of tachycardia. Both methods facilitated interpretation of all arrhythmia patterns, although PWD was of less practical value in cases of complete heart block. Conclusion: Simultaneous PWD recording of pulmonary vessels in the fetus allows accurate diagnosis of arrhythmias. It is easily obtained with standard ultrasound equipment and adds to the armamentarium of diagnostic techniques for assessment of rhythm abnormalities prenatally.
ObjectivesThe maternal near-miss case review (NMCR) has been promoted by WHO as an approach to improve quality of care (QoC) at facility level. This systematic review synthesises evidence on the effectiveness of the NMCR on QoC and maternal and perinatal health outcomes in low-income and middle-income countries (LMICs).MethodsStudies were searched for in six electronic databases (MEDLINE, Index Medicus, Web of Science, the Cochrane library, Embase, LILACS), with no language restrictions. Two authors independently screened papers and selected them for inclusion and independently extracted data. Maternal mortality was the primary outcome. Secondary outcomes included any outcome informing on any of the six dimensions of QoC: efficacy, safety, efficiency, equity, accessibility and timely care, acceptability and patient-centred care.ResultsOut of 24 822 papers retrieved, 17 studies from 11 countries were included. Maternal mortality measured before and after the implementation of the NMCR cycle significantly decreased (OR 0.77, 95% CI 0.61 to 0.98, eight studies, 55 573 043 women; I2=39%). A statistically significant reduction in the incidence of uterine rupture, postpartum haemorrhage and maternal sepsis was observed in three out of six studies. Ten studies reporting on maternal care process all showed some significant improvement when measured against predefined standards. All studies reported that the NMCR resulted in some amelioration of the facility structure (physical structure, staffing, equipment, training, organisation of care). Newborn outcomes were overall poorly reported; four studies showed no significant difference in perinatal mortality. Patient satisfaction and equity were also poorly reported.ConclusionsPolicy makers may consider implementing the maternal NMCR cycle approach among strategies aiming at improving QoC and reducing maternal mortality and morbidity in LMIC. Future studies should better document the effectiveness of the NMCR cycle particularly on outcomes reflecting patient-centred care and cost-effectiveness.
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